The most important disease(s) is(are)?

Judging by television news, you might think that breast cancer is the only disease that exists. If we wanted to spend money on the disease or group of diseases that results (by a considerable margin) in the greatest lost of quality of life years the world over, denying young (and older) people of their lives and quality of life, we would spend our money on mood disorders, schizophrenia, and bipolar illness.

Psychiatry is often knocked by the rest of medicine as being relatively unscientific (ie its all about talking). But the psychiatric community has probably gone farther than most in putting (with some success) their discipline on a scientific basis. One of the remarkable things about psychiatry is the presence of a codified scientifically based diagnostic process. This is diagnosis at the RDC or gold standard. How this is done is quite a remarkable story in itself. Science has an ongoing series of article about the latest revision of the DSM. The articles so far are 1) Proposed Revisions to Psychiatry’s Canon Unveiled, 2) DSM-V at a Glance, 3) Behavioral Addictions Debut in Proposed DSM-V, and 4) Experts Map the Terrain of Mood Disorders.

CONNECT VIA MYVPN TO GET WORKING LINKS TO SCIENCE!

Replacing an immune system … it’s hard to do a study

Science (2010-Feb-12) has an article about ablating and replacing the immune system in various autoimmune conditions. It appears that some people have ongoing remission from their conditions (MS, scleroderma, lupus etc). The problem is that some people die from the intervention. The intervention is now being down only at very late stages of the illness because doctors can’t risk death at earlier stages. But it seems reasonable that the intervention would be more efficacious earlier. Would you sign up for a trial? What kinds of studies are sufficient to implement this therapy?

“It’s devastating … no going back to normal.”

Friday’s Globe and Mail had an article about women with breast cancer. These women were/are given a choice of four cycles of Taxotere, or twelve cycles of Taxol for their cancer. The efficacy of these two alternatives is about the same (apparently).

Taxol, the cheaper generic, has “a very tiny risk of permanent hair loss.” Taxotere has a 3 in 100 chance of permanent hair loss (alopecia universalis). This means permanent loss of all body hair (eyebrows, everything). Another study puts this likelihood as high as 6 in 100.

Most women, when given a choice, choose Taxol.

The company’s (Sanofi) response to this is: “We fully understand that persistent alopecia may be a burden for patients, but still we consider it’s certainly something which is not life-threatening or is not something which impairs the likelihood of survival.” In other words, “we saved your life, so there.”

Sounds  like a case of POEM, and a situation where values enter the equation. CDA anyone?

Blood-pressure cuff can curb damage of heart attack

Having an open mind is part of being a scientist. The Globe and Mail has an article about a clinical trial resulting from an idea of Dr. Andrew Redington (Hospital for Sick Children, Toronto). During the ambulance ride to hospital, people with suspected MI were randomized to having a blood pressure cuff inflated and deflated for alternating five minute periods (repeated four times). Once at the hospital they received usual care. You can see the whole writeup at TheLancet.com (type Redington into the search field to find the article).

More Avandia

From the “you’ve got to be kidding me” file, here is an article from the New York Times, about how GlaxoSmith-Kline attempted to co-opt Dr. Steven Nissen (Cleveland Clinic) when they found out about his upcoming study about the risks of Avandia. Highlights: a scientist who is reviewing Dr. Nissen’s manuscript sends a copy to GSK, GSK then starts lying, and just can’t stop once they start. Dr. Nissen tapes his meeting (legally) with GSK. The lies can’t be denied.

How does medical science move forward if this is how things work?

How’s this for freedom of expression?

A British science journalist, Simon Singh, wrote in an editorial in the Guardian newspaper that certain aspects (eg spinal manipulation for asthma) of chiropractic were “bogus.” He was successfully sued and is now appealing this decision. Read about it here, and thank your lucky stars that in Canada we would probably (in the US certainly) be allowed to say what Mr. Singh said.

Efficacy and effectiveness are different! Effectiveness matters!

As you read the guidelines for your major project, you read in the AFP article that you should think about and emphasize POEM (Patient Oriented Evidence that Matters) rather than DOE (Disease Oriented Evidence). Although we hardly ever need new terminology, the authors decided to come up with new terms for efficacy (DOE) and effectiveness (POEM).

Recently in the US Senate, there has been a discussion that has to do with POEM rather than DOE. It’s interesting that EBM makes it to the political arena.

The American discussion has to do with rosiglitazone (Avandia) and pioglitazone (Actos). Here’s the distinction between efficacy and effectiveness. If you look at these two drugs in terms of efficacy, they are both good, in that they both do what they are supposed to do (lower blood sugar) about as well. This is DOE.

Unfortunately, “The senators cited internal FDA findings that: “[T]here is no evidence that rosiglitazone [the generic name for Avandia] confers any unique health benefits over pioglitazone [Actos] while there is strong evidence that rosiglitazone confers an increased risk of [heart attacks] and heart failure compared to pioglitazone.” [Financial Times, 2010-Feb-22]

If you had a choice of taking Actos or Avandia, you would want to know this, and it would MATTER. This is information about effectiveness. I personally would not choose Avandia for myself. Because I read not only the DOE, but also the POEM. I want effectiveness as well as efficacy.

Another excellent summary of this discussion is in the New York Times. [Research Ties Diabetes Drug to Heart Woes, February 19, 2010-Feb-19]

Are there problems with the meta-analytic approach?

In short, yes. Can they be biased? Yes. Can they be unbiased? Yes. Kind of like everything else. An article in the New York Times looks at some of the issues when looking at a recent meta-analysis of antidepressants.

How effective is influenza vaccine?

This article from the Atlantic provides an overview of the ideas I mentioned in class about overall effectiveness of influenza vaccination. They call the membership bias “healthy user effect.” It gives enough information for you to be able to hunt down original sources if you care. Before, this gets controversial, let me say that I got both my flu shots this year. But then I’m one of those people (albeit only a “semi-healthy user” ) who might have produced the bias, right?

Our very own scandal, again!

In case you can’t get to the Medical Post article mentioned previously, here is a link to a story in the Montreal Gazette about our very own academic leader who apparently published (as single author), an article she didn’t write. Fortunately the contents of the article (about estrogen) are all true, and can guide us when we think about estrogen as a therapy.

You can’t always do an RCT

Today’s New York Times has an article about a 43 hour surgery to remove an abdominal tumor that involved ex-vivo resection of the tumor. Read the article, and ask yourself how much evidence, of what strength, it would take to make you decide to have this operation if you had this condition. You won’t ever be able to find an RCT on the topic!

More on MS as a vascular disease

Today’s Vancouver Sun has an article here about patients coming to the False Creek Surgical Centre to get MRIs and ultrasounds to see if they have the venous outflow obstruction that Dr. Zamboni has hypothesized is causal in MS. There is an interesting discussion, including a mention of the apparently high rate that re-occlusion occurs after initial treatment etc.

One patient, who has MS, but apparently not the venous obstruction, says: “”The results in Vancouver were puzzling because my understanding is that Zamboni is saying that almost all MS patients have blockages, but none were found in my case. A doctor told me that there may be narrowing in veins that weren’t seen. Still, I’m not going to not go [to Italy].”

How likely do you think it is it that this will turn out to be a revolution in thinking about causation and treatment about MS?

You can read Dr. Zamboni’s article here. (VPN connection to eJournals at UBC Library; find Volume 50, Issue 6, Pages A1-A26, 1348-1358.e3 (December 2009) Think about what a reasonable next step would be given the information in the article.

Is MS a vascular disease?

Take a look at this article from the Toronto Globe and Mail (Saturday Nov-21-2009), which describes how a researcher’s hypothesis about his wife’s MS led to a potential new treatment. There is a description of some trials of a new therapy.

Go out on a limb, now rather than later! How likely is it that we are witnessing an actual breakthrough?