Posts filed under Medical news (341)

From BBC Radio: listen online

On Start the Week Emily Maitlis talks to the Executive Chairman of Google, Eric Schmidt about the digital future. A future where everyone is connected, but ideas of privacy, security and community are transformed. Former Wikileaks employee James Ball asks how free we are online. The curator Honor Harger looks to art to understand this new world of technology. And worried about this brave new world? David Spiegelhalter, offers a guide to personal risk and the numbers behind it.

(via @cjbayesian)

First, the serious one.  Nature News has a story about new immune-based cancer treatments (like Herceptin for breast cancer), some of which are very effective, but which are increasingly expensive.  In contrast to previous `small molecule’ drugs, these won’t necessarily get cheap when the patent runs out, since generic  (technically, `biosimilar’) versions are harder to make and test.

Now for something completely different

By @altonncf — via various people on Twitter who don’t cite original sources. Pro tip: Google Image Search is quite good at finding originals.

From XKCD

Stuff has a headline “Overseas advice: ‘Don’t test party pills on animals’” and lead:

New Zealand will fly in the face of international animal welfare conventions if it allows legal highs to be tested on animals.

However, if you actually read the story, you find that this is not just misleading, but clearly untrue.

They mention responses from three countries. In Canada

… unable to find “any information suggesting” there was a ban on using animals in recreational drug or alcohol research testing in Canada.

In France and the EU

But France recently banned the use of animal testing in the cosmetic industry and policymakers are under pressure to extend that to the legal high, alcohol and tobacco industry.

The European Union has also introduced a ban on the sale of any cosmetic or personal care product which was tested on animals.

and only in the UK was the response consistent with the story

Judy MacArthur Clark, head of the animals in science regulation unit at UK’s Home Office, replied that any proposal to test for the safety of recreational drugs would be “rejected”.

You might also ask how these countries test legal highs for safety, if they don’t use animal testing.  The answer, of course, is that they don’t test legal highs for safety. Not one of these countries has legislation or procedures for approving and regulating new recreational psychoactive substances, but they all do require animal testing for new medications, two facts that Stuff might have considered mentioning.  The reference to LD50 lethal toxicity testing is especially misleading, since the same paper claimed credit in January for the fact that LD50 tests had been ruled out by the Minister.

The ‘legal highs’ regulations are new. No other country has anything similar.  New Zealand can’t base its testing regimes on what other countries are doing, because other countries aren’t doing it.  It would be useful to have some informed public discussion on how testing should be done, since it does involve the sort of tradeoffs where, in a democracy, the public should have input. This sort of story doesn’t help. Quite the reverse, in fact.

[Update: Here are three research papers involving animal (mouse and rat) testing of synthetic cannabis compounds done primarily for regulatory or forensic purposes, in Australia, the US, and Russia]

The British consumer magazine Which? ran a mystery-shopper investigation of UK pharmacies recently.  One of the topics they covered was homeopathic products, and in 13 of the 20 pharmacies where they asked about homeopathic remedies they got advice that violated the Royal Pharmaceutical Society guidelines for pharmacists.  An information sheet from the society says that pharmacists should

when asked, assist patients in making informed decisions about homoeopathic products by providing the necessary and relevant  information, particularly the lack of clinical evidence to support the efficacy of homoeopathic products. They must also ensure that patients do not stop taking their prescribed medication if they take a homoeopathic product. Importantly, pharmacists will be in a position to discuss healthcare options and be able to identify any more serious underlying medical conditions and, if required, refer the patient to another healthcare professional.

(the most current guidelines are not available to non-members, but similar advice is quoted by Which?).

One of the responses to these findings has been that the survey is too small to draw any conclusions, but as Ben Goldacre points out, if the sample is representative, a sample size of 20 is enough to be worried

Pharmacists claiming @whichconvo 13/20 survey isn’t enough evidence whi.ch/ZhOSRL 95%CI on 13/20 is 44-86% bit.ly/14I5pxp

— ben goldacre (@bengoldacre) May 24, 2013

With sample sizes this small, different ways of calculating the uncertainty give visibly different results (I get 41%-85% in R), but the practical implications are the same.  If we can trust the sampling, at least 40% of pharmacists are providing advice that’s contrary to their professional guidelines and, since the mystery-shopper scenario was a patient who’d had a persistent cough for a month, advice that could actually be dangerous.

It would be interesting to know what the situation is like in NZ, especially as homeopathic products are specifically exempted  from the new rules that will require evidence to support health claims.

A round-up of some worthwhile links on Angelina Jolie and BRCA1

• Angelina Jolie. My Medical Choice
• Hilda Bastian (evidence-based medicine specialist and cartoonist) Keeping Health Risks in Perspective When the Dramatic and Rare Goes Culturally Viral
• Melanie Tannenbaum (social psychology) Why It Matters That Jolie Wrote About Her Medical Choice
• David Gorski (surgical oncologist and curmudgeon) Angelina Jolie, radical strategies for cancer prevention, and genetics denialism
• Gayle Sulik (medical sociologist) Angelina Jolie and the one percent
• Breast cancer screening in NZ. BRCA genetic testing is recommended and subsidized only for women with a strong family history, and where possible should start by testing one of the affected relatives to make sure that the familial pattern is actually due to BRCA1 or BRCA2 mutations, not some other gene.
• What’s actually patented in the evil gene patent.  The most important part of patent covers the short ‘mirror-image’ DNA molecules needed by the current testing technology: it will be a race to see if sequencing-based tests make the patent obsolete before it expires in 2015 (or, potentially, is overturned by the US Supreme Court later this year).

As part of International Clinical Trials Day, the UK National Health Service is launching “It’s ok to ask”:

Clinical research is the way in which we improve treatments in the NHS. In many cases doctors will tell patients about research but we also need patients to ask about it and keep research at the top of the NHS agenda.

In a recent consumer poll, only 21% of patients and the public said that they would feel confident asking their doctor about research opportunities – a low number.

That is why during 2013/14 The National Institute for Health Research (NIHR) is promoting the fact that it’s OK to ask about clinical research.

The campaign is aimed at patients, medical professionals and the public. Everyone can get involved and help spread the word that it’s OK to ask about clinical research.

The campaign is in the UK, but it’s ok to ask in NZ too.

Two hundred and sixty six years ago today, James Lind began what is regarded as the first proper controlled clinical trial

On the 20th May, 1747, I took twelve patients in the scurvy on board the Salisbury at sea. Their cases were as similar as I could have them. They all in general had putrid gums, the spots and lassitude, with weakness of their knees. They lay together in one place, being a proper apartment for the sick in the fore-hold; and had one diet in common to all, viz., water gruel sweetened with sugar in the morning; fresh mutton broth often times for dinner; at other times puddings, boiled biscuit with sugar etc.; and for supper barley, raisins, rice and currants, sago and wine, or the like. Two of these were ordered each a quart of cyder a day. Two others took twenty five gutts of elixir vitriol three times a day upon an empty stomach, using a gargle strongly acidulated with it for their mouths. Two others took two spoonfuls of vinegar three times a day upon an empty stomach, having their gruels and their other food well acidulated with it, as also the gargle for the mouth. Two of the worst patients, with the tendons in the ham rigid (a symptom none the rest had) were put under a course of sea water. Of this they drank half a pint every day and sometimes more or less as it operated by way of gentle physic. Two others had each two oranges and one lemon given them every day. These they eat with greediness at different times upon an empty stomach. They continued but six days under this course, having consumed the quantity that could be spared. The two remaining patients took the bigness of a nutmeg three times a day of an electuray recommended by an hospital surgeon made of garlic, mustard seed, rad. raphan., balsam of Peru and gum myrrh, using for common drink narley water well acidulated with tamarinds, by a decoction of wich, with the addition of cremor tartar, they were gently purged three or four times during the course.

The consequence was that the most sudden and visible good effects were perceived from the use of the oranges and lemons; one of those who had taken them being at the end of six days fit four duty. The spots were not indeed at that time quite off his body, nor his gums sound; but without any other medicine than a gargarism or elixir of vitriol he became quite healthy before we came into Plymouth, which was on the 16th June. The other was the best recovered of any in his condition, and being now deemed pretty well was appointed nurse to the rest of the sick …

Lind knew very little about scurvy apart from the typical progress of the disease, and he had no real idea of how the treatments might work.  That’s a handicap in coming up with ideas for treatment, but not in doing fair tests of whether treatments work.

The trial didn’t have an untreated group: all the patients got one of the treatments recommended by experts.  There’s no need for a controlled trial to have an untreated group — if there is an existing treatment, you want to compare to that treatment; if there is none, you may want to compare immediate vs delayed treatment.

Despite the dramatic success of fruit juice in the trial, it wasn’t adopted as a treatment. That, sadly, can still be the case today.  New drugs or surgical techniques are taken up enthusiastically, but boring interventions like nurse home visits or surgery checklists get less attention. Still, things are much better than they were even twenty years ago. Nearly all of medicine accepts the idea of randomized controlled comparison, and it is spreading to other areas such as development economics.

There are two excellent, free books about clinical trials and health choices: Testing Treatments, from the James Lind Initiative, and Smart Health Choices, from Les Irwig (at Sydney Uni) and coworkers.

Much of clinical trials development is unapologetically technical, but there are important areas where public participation can help:

• The James Lind Alliance asks patients and clinicians to say what questions matter most.  Clinical trials still tend to answer questions that are scientifically interesting or commercially important, not what actually matters most to patients
• The Cochrane Collaboration is attempting to collect and summarise all randomized trials.  The Cochrane Consumers Network is for non-specialist participation — in particular as Consumer Referees to help ensure that summaries of research address the questions that are important to consumers and are presented in language that consumers can understand.
• Ethics Committees that review clinical trials and other human research in New Zealand are required to have non-specialist community members. This is a substantial commitment, but one that is important if ethics committees are to be more than just red tape.
• And if you haven’t yet signed the AllTrials petition, calling for the results of all clinical trials to be published so we can know what treatments work, now would be an excellent time.

From the Wellcome Trust Monitor, a survey examining knowledge and attitudes related to biomedical science in the UK

The survey found a high level of interest in medical research among the public – more than seven in ten adults (75 per cent) and nearly six out of ten of young people (58 per cent). Despite this, understanding of how research is conducted is not deep – and levels of understanding have fallen since 2009. While most adults (67 per cent) and half of all young people (50 per cent) recognise the concept of a controlled experiment in science, most cannot articulate why this process is effective.

Two-thirds of the adults that were questioned trusted medical practitioners and university scientists to give them accurate information about medical research. This fell to just over one in ten (12 per cent) for government departments and ministers. Journalists scored lowest on trustworthiness — only 8 per cent of adults trusted them to give accurate information about medical research, although this was an improvement on the 2009 figure of 4 per cent.

I’ve got no objection to speculative or controversial research being in the media, as long as it’s marked as such, which it often isn’t.

In September, the Herald told us researchers were finding that dementia was due to high blood sugar, essentially a diet and exercise problem.

Today we learn that it’s actually ‘technology’ that causes dementia, in a, like, totally interconnected way

“Considering the changes over the last 30 years – the explosion in electronic devices, rises in background non-ionising radiation – PCs, microwaves, TVs, mobile phones; road and air transport up four-fold increasing background petro-chemical pollution; chemical additives to food, et cetera,” Professor Pritchard said.

“There is no one factor rather the likely interaction between all these environmental triggers, reflecting changes in other conditions.”

What actual research paper found is that the ratio of  diagnoses of neurological diseases  to deaths had risen, across 16 countries, indicating that people live longer after diagnosis.  This could be due to earlier onset, the explanation Prof. Pritchard gives, but they actually don’t do any correction for changes in diagnosis.  Earlier diagnosis could just mean earlier diagnosis, not earlier onset of disease.  Changes in how deaths are classified could also have played a part, although these are less likely to be consistent across countries.

The research paper makes a lot of the fact that dementia in women increased later than in men, attributing this to women entering the workforce and getting exposed to more scary modern stuff (without any actual data on the relative exposure to modern stuff in the workplace and at home).  Surely another possible explanation is that in the modern world, loss of memory and cognitive function is taken seriously in elderly women, but that 30 years ago it just wasn’t regarded as a medical problem.