May 10, 2015

Some fun with medical backflips

Today is fun day for poking holes in popular health myths.  My pervasive skepticism is getting a lot of support at the moment.  All the research reports below are from "JAMA Internal Medicine", a most prestigious medical journal

Wow!  How the statin worm has turned!

The cholesterol fanatics were until very recently so evangelical about statins that they were urging for them to be put into the water supply.  Just the title of the article below would have been unthinkable two years ago.  There are a few of us who have been saying for years what a deadly hoax the statin craze was but we were like climate skeptics against global warming:  The whole establishment was against us. The conclusion below?  Even very ill people were on balance better off WITHOUT statins.

The whole point of the article is something that is still sometimes denied:  The often severe side effects of statins and the severe impact of those side effects on the patient's quality of life (QOL).  A lot of apparent Alzheimer's cases have been in reality sufferers from statin side-effects

Safety and Benefit of Discontinuing Statin Therapy in the Setting of Advanced, Life-Limiting Illness: A Randomized Clinical Trial

By Jean S. Kutner et al.

ABSTRACT

Importance:  For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy.

Objective:  To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting.

Design, Setting, and Participants:  This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach.

Interventions:  Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins.

Main Outcomes and Measures:  Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings.

Results:  A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, −3.5% to 10.5%; P = .36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P = .04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were $3.37 per day and $716 per patient.

Conclusions and Relevance:  This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted.

SOURCE

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Hurrah for peanuts! (Goober nuts; ground nuts)

"Prospective Evaluation of the Association of Nut/Peanut Consumption With Total and Cause-Specific Mortality" by Luu, Blot et al. (Yes. They are real names) reports that you live longer if you eat more peanuts. The study was methodologically strong but the effects were trifling -- rather like saying that if you eat a lot of peanuts you will live longer by one week. With the large sample sizes, the effects were statistically significant but they were not significant in any other way.  Eat as few or as many peanuts as you like.  I guess that's good news for people with peanut allergies.

A jarring note about this study is that the journal editor (Mitchell H. Katz) put up a note that showed no awareness at all of how small the effect size was.  He claimed it as a great health recommendation for peanuts.  Amazing.  I guess medical researchers have got used to reporting trifling effects.

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Vegetarians have healthier bottoms

We read:  "Vegetarian diets are associated with an overall lower incidence of colorectal cancers. Pescovegetarians in particular have a much lower risk compared with nonvegetarians. If such associations are causal, they may be important for primary prevention of colorectal cancers."

How splendid to see in the medical literature for once that proper caution:  "If such associations are causal".  The study is worth noting for that alone.  The effects noted were however very small so it's not worth going vegetarian in order to dodge bowel cancer.

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An apple a day does NOT keep the doctor away

Sad news for apple growers, I guess.  "Association Between Apple Consumption and Physician Visits" reports:  "Evidence does not support that an apple a day keeps the doctor away; however, the small fraction of US adults who eat an apple a day do appear to use fewer prescription medications".  The data were derived from a large and well-sampled subject pool so the findings are pretty conclusive, at least for the USA.

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I have kept the best 'til last

"Responses of Specialist Societies to Evidence for Reversal of Practice" is worthwhile just for the title.  Medical backflips are so common that they can now be studied as a subject of interest by themselves. The authors found that specialists were quick to adopt poorly founded practices and slow to let them go.

It's a good lesson in always questioning authority.  Authorities are often wrong.  The questioning has to be reasonable, however.  An insistence on seeing the evidence is what is needed.  If you don't know much about statistics but want to read articles in medical journal, just remember the official rule of thumb:  Hazard ratios of less than 2.00 are not sound evidence.  The hazard ratios in the studies mentioned above were all MUCH weaker than that.  None of them even rose as high as 1.00.  Amazing.





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