During my fellowship in allergy, I worked with family in which 7 boys were affected with X-linked agammaglobulinemis. I published a paper about their interesting presentations. One of my kids today had this condition and a number of associated problems. It was refreshing and hopefully helpful to the family who was here to see me about possible allergies.

The next was a young man of 12 years who had over the past year complaints of a scratchy throat, itchy mouth, and a garbled voice after eating watermelon. It also happened with banana, grapes, avocado, and cantelope. This is the oral allergy syndrome. I struggle with this too. My reaction to watermelon prompted one of our allergy fellows at Henry Ford Hosptial to do a research project on the problem. That work also resulted in a publication.

So two of my three patients today had clinical problems that I had written about and had published on.

It was a great day indeed.
FEL

“Most children with a history of a mild egg allergy (defined as hives) can receive the influenza vaccine safely in the office without the need of an allergy consultation.”

That conservative approach with skin testing, desensitization, or challenge dosing are not recommended. There are however a few precautions-

Resuscitative equipment must be readily available in the office

Those who have an egg story should be kept in the office for 30 minutes after the immunization is given

For those who need a second dose, the same product/brand is preferred if possible, it does not have to be of the same lot.

An allergy consultation should be asked for any child who has a severe reaction to egg. That severe reaction is defined as a reaction that involves the cardiovascular system, the respiratory tract, the gastrointestinal tract, or any child who needed epinephrine for a reaction to egg.

The algorithm is as follows-

It is important to protect our children from the ‘flu’. These new recommendations should make it easier for those who have struggled with a diagnosis of egg allergy and the need for a ‘flu’ shot. One situation that we are frequently asked about is what to do about those children who have a positive allergy test to egg and no history of exposure to egg? It would be great to see that statement here in this AAP guidance. However, the decision point stands- does the child have a history of an allergic reaction to egg- it does not ask if the child has a positive allergy test to egg. Again, the history of a reaction with exposure is what separates the allergic child from the sensitized child. My take on this is to let the history of clinical egg reactions dictate the determination of severity. In the truly nervous situation, the 10/90 may help get the family through this. Often times the allergist could take care of these situations for the primary caretaker. What helps is for us to know comfort levels on behalf of the referring physicians and the families. With accumulating evidence over the past year regarding egg allergy and this vaccination, I think next year’s recommendations will even more liberal.

FEL (September 2, 2011)

MedicalSchool Graduation

So we add a doctor of medicine to the family.

Our daughter-in-law, Amanda, graduated from medical school last weekend.

Now the really hard work begins-residency.

My recollection is that an allergist by the last name of Rome was the speaker. Since this was well before the days of the internet, I was unable to verify Dr. Rome. I would like to reference the author of the ‘Golden Rules of Pediatric Allergy’ and try to get a fix as to when these were written. My guess is that this is from the  1960’s. These ‘rules’ are almost 50 years old.

I love history. If you know your history you know where you come from and that helps when you set your sites on where you need to go. Allergy enjoys a history as well. So, where did these come from? Was there evidence to support these contentions?

Some of these statements have gone by the wayside- many have been disproven over time (that is what evidence-based medicine will do), some have never been proven to be true, some may be dangerous given our current knowledge, and some still remain true to this day- especially rule #33.

Some of these rules are still being practiced, prescribed and proscribed. You could almost tell when a physician was trained when some of these re-surface. I had rule #45 present recently.

This will be a dynamic document. My plan is to look into each rule, try to determine why it became a rule. Then see what we have in the 21^st century to support or refute it.

So, I will need support on this project. Please feel free to help with comments and hopefully references.

Also note that I retyped the ‘rules’ and was exact in my work. What follows is verbatim, including any and all grammatical and spelling errors. Please click the link to access the ‘Golden Rules of Pediatric Allergy’.

FEL

In the past, influenza vaccination was a concern in a child who had an egg allergy. In this situation, the vaccine was either not given or the child underwent a desensitization procedure in the allergist’s office. Current research has caused a re-thinking of the previous guidelines. Now it is not just having an egg allergy that would preclude the vaccination, it is the nature of that allergic response to egg that guides the decision for vaccination.

The influenza vaccination does contain egg products. The amount of egg in the vaccine may vary depending upon the manufacturer and even within distributed lots of the vaccine from the same manufacturer. Once upon a time we thought that if food which contained egg was tolerated, but egg was not, then the vaccine could be given. A few years ago that adage was proven to be incorrect. The nature of the egg protein in the vaccine may differ from the egg in a ‘heated egg’ food product.

Our allergy clinic at Riley has received many calls from worried families and from primary care offices regarding egg allergy and the influenza vaccine.

My partner, Dr. Girish Vitalpur spoke at our recent ’2010 Pediatric Pulmonary Update: Today’s Challenges’ on this very topic of egg allergy and the flu vaccine. The entire conference was dedicated to specific management problems that primary caretakers face: the issue of egg allergy and the vaccine was a notable concern.

Girish and I thought it may be of service to those who could not attend the meeting to post the recommendations and the approach to influenza vaccine in the child with egg allergy.

First a few fact that he shared (all were referenced)

• 1969- one death reported due to anaphylaxis to the vaccine in someone with egg allergy
• 1976- one case of anaphlyaxis per 4.4 million vaccinations with none occurring in an egg allergy individual
• 1990-2005- 747 million influenza vaccine doses given with 4 cases of fatal anaphylaxis

Balance these facts with 540,000 deaths due to influenza during the same time interval.

Flu vaccine recommendations are dependent upon the type or severity of a reaction to egg. The following sorts out considerations for egg allergy severity.

Mild Egg Allergy

• Hives around the mouth/face
• Mild itching
• Nausea
• Itchy mouth

Severe Egg Allergy

• Respiratory changes
• Cardiac changes
• Oral swelling or throat tightness
• Systemic hives
• Multiple organ reactions-hives with vomiting, hives and respiratory symptoms for example

Note- just having a positive test for egg and no history of a reaction is not listed here as a severity consideration.

Current Guidelines (6 months to 18 years of age)

No egg anaphylaxis- may receive the vaccine in a two dose graded manner (graded challenge).

INFLUENZA VACCINE ADMINISTRATION WITH EGG ALLERGY:  MANAGEMENT

• Office must be prepared for anaphylaxis
• Informed consent needed
• Approaches

1.  Administration of vaccine as a single dose

2. Graded Challenge

                  Give 10% of vaccine.  Wait 30 minutes.  Give rest of vaccine.  Monitor for 30-60 minutes (30 minutes usually- 60 minutes depending upon the history).

 3.  Desensitization (for cases of egg anaphylaxis and/ or adverse reaction to the vaccine)

       Administer vaccine in 4-5 incremental doses, at 15-minute intervals

 Zeiger, 2002;Greenhawt, 2010

The desensitization for anaphylaxis should be performed in the allergist’s office.

The graded challenge has been done in primary care offices- it fulfills that gray zone when there are no clear answers and there is anxiety on behalf of the family and the primary caretaker.

Hopefully this posting will help to answer questions about giving the vaccination in someone with an egg allergy. My thanks to my colleague, Dr. Girish Vitalpur for putting this together.

FEL

S. Sicherer, R. Wood, D. Stablein, R. Lindblad, W. Burks, A. Liu, S. Jones, D. Fleischer, D. Leung, and H. Sampson. JACI 2010 in press

How does peanut sensitization occur? How can we prevent peanut sensitization? What are the risk factors associated with the development of peanut allergy?

There are  very few proven answers to these questions. The number of theories to explain this abound. Thankfully we are seeing more clinical research intent on finding answers to this common problem of peanut allergy (sensitization). Of note, many of our recommendations for preventing peanut allergy/sensitization have been challenged. This is in part due to the existence of a paucity of data to support current recommendations and conflicting results from newer studies. This article is the latest on the topic of risk factors for the development of peanut sensitization. The article will be published in the Journal of Allergy and Clinical Immunology 2010.

Current recommendations from the American Academy of Pediatrics (American Academy of Pediatrics, Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000;106:346-349.)are that peanuts should be avoided during pregnancy and lactation for an infant at risk for developing allergy. Two studies (published in 1996 and 2003) challenged that concept and concluded that peanut consumption during pregnancy/lactation was not a risk factor. We now have a much larger study performed with specific attention to mother’s dietary history that has concluded that peanut ingestion during pregnancy is indeed a risk factor.

The Purpose of the Study

The study came from the Consortium of Food Allergy Research. Five sites contributed to the work. This is a report on the clinical, demographic, and immunologic factors that were associated with an elevated specific IgE (value greater than 5 kU/L) to peanut (done by a blood test for peanut antibody) in a large group of children with known egg or milk allergy (without previously known peanut allergy). The specific interest was the discovery of a behavior that could be modified if relevant- mother’s ingestion of peanuts during pregnancy and the frequency of that ingestion.

Methods and Subjects in the Study

The cohort group was 512 infants and children, 3-15 months of age at enrollment (average age 9.4 months). To be in this group, the children had to have an allergic reaction and a positive allergy skin prick test to egg and/or milk. No child with a known peanut allergy or with a positive peanut specific IgE (blood test) done prior to the study was enrolled.

Questions were answered about the diet, the social situation, and the environment. There were five categories for maternal peanut ingestion; total avoidance, ingested <2 times/week, ingested more than 2 times/week, ingested daily, or unknown. The term ‘frequent’ meant that peanuts were eaten 2 or more times in a week.

Allergy testing included skin testing, blood tests for specific IgE, and tests for specific IgG to peanut.

What they found

A specific IgE of 5 kU/L or greater was selected as the cut-off point for evaluation. This was the level that was associated with more than a 70% chance of having a reaction to peanut (taken from other studies). There were 140 children (27.8%) who had a peanut specific IgE to peanut >5 kU/L.

The results were presented in a number of different ways; univariate analyses, multivariate analyses, and an analysis for receiver operator characteristics.

Looking at how a number of variables that could act alone as risk factors: there was no association between peanut IgE >5 kU/L and age at enrollment, age when formula was introduced, age when solid food was introduced, household income, parent education level, atopic disease in the parent, exposure to soy formula, breastfeeding, type of birth delivery, or use of antibiotics.

The variables that have a significant association included the following; male sex, race, atopic dermatitis severity, and peanut consumption during pregnancy >2 times/week. Peanut specific IgE was highly correlated to egg and milk specific IgE levels.

There was a dose-response associated with mother’s peanut consumption and peanut specific IgE >5 kU/L- the more peanuts consumed-the greater chance of having a child with a peanut specific IgE >5 kU/L. Further analyses showed peanut consumption during breast feeding to have no association with peanut IgE in one model of analysis.

Using a linear regression analysis and adjusting for egg IgE, milk IgE, severity of atopic dermatitis, sex, study site, and race, only peanut ingestion during pregnancy predicted peanut specific IgE.

The ratio of IgE to IgG for food has been noted to decrease for those who have achieved natural tolerance or in those who have undergone oral immunotherapy. A high IgE to IgG ratio may be related to a higher risk of demonstrating allergic reactions.

Conclusions

In a dose-dependent fashion (increase the amount eaten by the mother leads to an increase in sensitization of the child) mothers eating peanuts during pregnancy was associated with an increased chance of peanut allergy developing in the child known to have egg and/or milk allergy.

The factors that have been associated with this included; male sex, nonwhite race, and elevated milk/egg IgE levels.

Cautions and Concerns

The observation that boys tend to have more food allergy is well known. In regards to race, Asians tended to be at higher risk. The association with egg /milk allergy as a risk factor was not unexpected. Sensitization to these multiple foods is known from previous work.

Atopic disease was not a risk factor; however this group of children was selected for having atopic disease. There was no association with soy ingestion and peanut sensitization (both are legumes). There was also no association with the use of medications to suppress gastric acid. Having peanuts in the home was also not a risk factor in this group.

The authors point out that this was an observational study. They found associations or risk factors- not causative factors. To prove allergy, a peanut challenge would be required.

My comments

This report is to be published in an excellent peer-reviewed journal with authors who have national if not international reputations for excellent science in the world of peanut allergy.

The problems with other studies similar to this were identified in the discussion part of this study. One of the problems is the recall of peanut exposure during pregnancy by the mother. Here the enrollment and history was taken soon after birth. It was hoped that dietary exposure history would be less biased with this approach.

The study also points out that this was sensitization to peanut and not clinical peanut allergy: there was no history of a peanut reaction in these children. They worked with a laboratory value that was associated with a high risk of having an allergic reaction taken from a different group of children. So there was a very good chance that a reaction could occur.

The results also pertain to a specific population. The study was performed in a group of children who were selected due to known egg/milk allergy.

So the mothers of children who currently suffer with egg/milk allergy should not have eaten peanuts 2 or more times per week during pregnancy. This sounds like advice given too late to make a difference. The point however is the association of peanut ingestion in pregnancy with peanut sensitization in known egg/milk sensitive children.

The AAP recommendation is that mothers with infants at risk for atopy should not eat peanuts during pregnancy.  So that ‘at risk’ infant would be one with one parent and/or two parents, and/or a sibling with allergy.

Clearly more work is needed before declaring these associations as recommendations. This is the latest work on risk factors.  Mothers that eat peanuts less than twice a week may decrease the risk of peanut sensitization, if the child goes on to have egg/milk allergy. They may also not worry about eating peanuts during breast feeding of a child who has known egg/milk allergy.  

This also begs the question of how many peanuts were eaten. This is a frequency factor (>2 times per week). Perhaps there is a quantity factor as well. My guess is that a serving work be considered the standard exposure. One resource lists one ounce of peanuts or two tablespoons as a serving. The authors point out that this group needs to be followed with a peanut challenge in their future.

This was a fascinating study to read and review.

FEL

A message was forwarded to me about a news broadcast from Chicago that highlighted a tool that can be used to help with asthma diagnosis and management. The FDA has recently approved this according to the message. This tool is the measurement of exhaled nitric oxide (eNO). In allergic asthma  airway inflammation involves numerous inflammatory cells especially eosinophils. These inflammatory cells have a marker for their involvement and activation called nitric oxide. We are able to measure this by-product of airway inflammation in the breath. I also received another link on this measure of airway inflammation. In this second newsbroadcast Dr. Wolfe, an allergist, does a nice job in explaining this test, this measure, and allergic asthma.

This is not a new procedure. At Riley Hospital our group has been using this measurement in the care of children with asthma. It is nice to see that the concept of eNO is catching on and its value is appreciated.

I feel that a measure of eNO offers a significant amount of information regarding the role of allergy and the level of control patients with asthma have. I use eNO measures frequently in my Allergy/Asthma practice.

FEL

The comment in question was posted to my October 15, 2009 entry titled Phadia Allergy Tests and Asthma .

The commenter disagrees with my interpretation feelings towards in-vitro testing. I am, in the commenter’s perspective, being self-serving by berating this type of allergy test in favor of high cost allergy skin tests that are “archaic”. The commenter also pointed out that it would be impossible for all 23 million patients with asthma to be seen by the 4,000 practicing allergists, and thus most asthmatics must be managed by the primary caretaker. The commenter points out that it is a disservice to disallow a patient to know the ‘root of their problem’–and in their practice, the immunocap is used daily to uncover the triggers that are causing symptoms. Mention is made of two studies in which allergists ‘…cannot guess sensitivities based on history or physical alone by more than 50%’. The comment ends with the commenter hoping that I and my allergy colleagues feel good about a futile and self-serving vendetta against in-vitro allergy testing. I was then challenged to talk about something called ‘allergy component’ testing.

There are quite a few issues here.

1. I use the Phadia Immunocap for IgE levels to specific foods. This is how we look for possible food allergy resolution. For many foods a specific concentration of specific IgE antibody is related to a risk of a reaction with exposure. We proceed with a food challenge based on the value of an in-vitro test. Without the in-vitro tests our practice would not have so many successes in outgrowing food allergies. IN-VITRO TESTS HAVE VALUE. I USE IN-VITRO TESTS.

2. I do have specific issues with in-vitro testing and that is the use of a PANEL. Too often the panel contains items that are not relevant (meaning there is no exposure to the allergen). The panel wraps a number of items and offers specific IgE at one price. Representatives from the ‘in-vitro testing industry’ recognize that this is an issue. However, by adding additional items a higher price can be justified.

      For example look at one Michigan hospital’s Phadia ImmunoCAP Food Allergy Panel - Clam, Egg White, Codfish, Corn, Milk, Peanut, Scallop, Shrimp, Soybean, Walnut, Wheat, and a total IgE. As individual in-vitro tests these can be $100 a piece. By the way, a skin prick test is about $10 per item. There clearly are a few foods on here that are not part of the usual diet- they are not clinically relevant. How many infants who have atopic dermatitis are eating scallops, shrimp, and clam? A food panel that contained egg white, wheat, soybean, codfish, peanut, and milk would be appropriate. A second panel with the shellfish and a third with the tree nuts would be very acceptable if used based on the food exposure history.

      A report by Anna Wetherbee in the journal Lab Medicine, November 2007 (Vol 38, no. 11 649-650)talks about the clinical appeal of in-vitro testing and the use of allergen panels. Interestingly, primary care physicians have been slow to embrace in-vitro testing partially due to a questionable total value proposition. The panel offers 15 or more specific allergens and billing for the panels is computed on a per allergen basis where the cost can be as much as $185 (Medicare fee schedule)

POINT- ORDER SPECIFIC ITEMS RELATED TO THE TIMING OF SYMPTOMS. AVOID PANELS.

3. The value of any allergy test is only as good as the history that supports it. The test makes no one allergic, it only demonstrates the production of IgE antibody which may or may not be relevant. They cannot be used to predict alllergy and the clinician needs to assess the clinical relevance of the test. Individual in-vitro allergy tests can do this. A set panel may not be appropriate for the seasonality of the patient’s symptoms. A simple example- if wheezing occurs August 15 and continues until the second frost then ragweed would lead the list of usual suspects. Of what use is the value for tree pollen given this history? A panel may obligate an analysis of other allergens that have no relevance and would add to the cost.

4. In-vitro testing overcalls inhalant allergy. Please see the results of the NHANES study(earlier posting in the blog ). This study involved a health survey of 4000 children and was published in a reputable journal. In this study the in-vitro test declared that almost 50% of the study population was allergic whereas by the children’s (parents’) history, only about 20% had symptoms of an allergic condition. The in-vitro tests are used extensively with our food allergy children and they are not as effective for inhalant allergy.

5. Intra-dermal skin testing is rarely done in our practice. The literature and evidence suggests that this type of test in most instances does not further the diagnosis.

6. If immunotherapy is considered, testing should be performed with the materials that are to be used in the immunotherapy extracts.

7. There are specific recommendations regarding when to refer to an asthma specialist. These can be found in Section 3 Component 1 page 68 of the 2007 National Heart, Blood, and Lung Institutes, National Asthma Education and Prevention Program, Expert Panel Report 3. There is no intention that every patient with asthma be seen by an allergist and clearly not every patient needs allergy testing. The use of allergy testing is considered within the context of severity and control with their subcomponents of risk and impairment.

8. I love to review articles. My training as a PhD student in pharmacology helped me learn the knack of critical review. My recent training in Public Health has added epidemiologic skills and insight to biostatistics. When I quote something it is always referenced so the reader can go to the source.

      There are two articles that have the batting average of an allergist at 500 for identifying a specific allergen by history or physical examination. I wonder, what was the gold standard in these studies? Remember, the best test for a trigger is a challenge. The history of seasonality or perennial exposures, symptom free days, and symptomatic days helps me sort out what I think is going on. The allergy tests help verify my clinical impression. Would you have the laboratory result determine the clinical impression or the history? Allergy tests can be falsely positive and falsely negative.

      The sensitivity of a test is the ability of the test to identify correctly those who have the condition of interest.

      The specificity of a test is the ability to identify correctly those who do not have the condition of interest (M.Szklo and F. Nieto, Epidemiology, Beyond the basics, 2^nd edition).

      In many reviews of the in-vitro tests, the sensitivity is high and even up to 100% for some allergens (correctly identifying those who are allergic). However, the specificity can be as low as 50%, correctly identifying those who do not have the condition. The in-vitro test can identify who has sensitization, however there as a fair number identified as having allergy by the test, but do no have symptoms (false positive results). We have to careful on how the results are interpreted. 

9. The email address of the person who wrote these comments indicated an association with a particular health care organization. I wonder what their background is—a physician, a nurse or a nurse clinician, a researcher, or a laboratory worker? The health care group has at least two allergy practices within its coverage. I wonder what the credentials of the commenter are in this area.

10. I am not sure what allergy component testing is. I entered the term in a search engine and got no results. I would be most happy to talk about it if I knew what it was.

I use in-vitro testing, I use the Phadia system for IgE. It is an excellent test when used in the proper context. I do, however, have issues with the marketing of panels, including cost, confusion, interpretation, outcomes. The use of these panels has generated a good number of referrals. I have been significantly busier with children (parents) coming for explanations, apprehensions, and fears based on what a panel revealed.  In the long run, if I was asked to pick what the 4 most important allergens to evaluate they would be house dust mites (two species), cat (if the history supports), dog (if the history supports), and cockroach (also history dependent). The family could actually do something about these exposures.

Fred Leickly

Evidence-based medicine (EBM) tries to provide a framework for treatment that is supported by the latest proven research. The article talks about this enhancing a medical practice. I think that patients and families should be aware of EBM. I can see value of EBM in the practice of allergy by board-certified allergists especially in an environment where the label of ‘allergy’ is given too loosely. In my practice I am seeing conditions labeled as allergy (apraxia, autism, sensory integration defects, ADHD to name a few) because tests for allergy return as positive. Many times the clinical condition and the test has nothing to do with allergy. IgG to food would be a prime example. I have seen significant amounts of money spent and hopes of families dashed by the use of tests and therapies that are not evidence-based.

The EBM approach first asks a very specific clinical question. The question could be about a test, a treatment, a diagnosis, or an outcome. Next the literature is searched for information on the topic. The information is then evaluated to see if it is valid, useful, and related to the question. The review of the literature looks critically at many different aspects of the scientific studies. The numbers, the methods, and the statistics are evaluated. The EBM may conclude that there exists type A evidence (great supportive studies in a large number of patients) that a treatment is effective.

Other support for diagnosing and treating can be found in ‘Guidelines’ . Many specialty organizations offer guidelines for common clinical conditions and the guidelines will incorporate EBM.

Resistance to EBM stems from concerns that it is a cookbook approach to medical practice. Another issue is how can a busy practitioner  integrate EBM into a practice. The article provides ideas and links for the practitioner.

Now the journal also had an excerpt from an article written by D. Isaacs and D. Fitzgerald that appeared in the British Medical Journal a few years ago (BMJ 1999;319:1618) that poked a little fun at EBM. What follows was the results of a poll that asked physicians what they would do if there was no solid evidence in the literature to help with a clinical decision. The article was titled, “Seven alternatives to evidence-based medicine”. This made me smile.

1. Eminence Based Medicine- The more senior the person, the less need for evidence. Experience outweighs evidence. Faith in clinical experience was defined as making the same mistake with increasing confidence over an impressive number of years.

2. Vehemence Based Medicine- Substituting volume for evidence as an effective technique for brow-beating a more timid colleague.

3. Eloquence Based Medicine- The perennial sun tan, carnation on the Armani suit, the silk tie accompany a tongue as equally smooth. Tailored eloquence and verbal eloquence are powerful substitutes for evidence.

4. Providence Based Medicine- If the caring practitioner has no clue what to do next, the decision may be best left in the hands of the Almighty.

5. Nervousness Based Medicine- The fear of litigation is a driving force for more tests and excessive treatments.

6. Confidence Based Medicine- Restricted to surgeons

Now I am puzzled- the quip in Physicians Practice said seven, I count only six. This second article ended and I could not find that seventh alternative. Finally, I found the original article at the Ruth Lilly Library on OVID. Here is number seven.

7. Diffidence Based Medicine- Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the doctor’s pride to do nothing (BMJ, 1999).

That was the original article on alternatives to EBM. Now it gets even better. Others have added to this list, we now have the following alternatives; Effervescence Based Medicine, Webidence Based Medicine, Profit Based Medicine, Annoyance Based Medicine, Propaganda Based Medicine, and Arrogance Based Medicine to name a few. We see a significant amount of Webidence Based Medicine. I urge caution with the internet. Look to sites sanctioned by well known organization- the American Academy of Pediatrics, the American Academy of Allergy, Asthma, and Immunology, the Food Allergy and Anaphylaxis Network, the National Institutes of Health, the National Heart, Lung, and Blood Institute to name a few. Profit Based Medicine – as a personal word of caution, ask about insurance coverage. Your insurance may not cover something because it is experimental or without EBM to support what is done. There is usually a reason why something is not covered by insurance. Ask about it.

I do my best to abide by evidence- based medicine. It makes sense to me. Evidence for my diagnosis, evidence for my selection of tests to help with that diagnosis, and evidence for the best treatment for the condition. Medicine is changing all the time. EBM helps evaluate what we have done and helps to consider what we need to do for the benefit of those we are taking care of.

Fred Leickly