Posts filed under Medical news (341)

The Herald has a completely over-the-top presentation of what might be an important issue. The headline is “Hospital choice key to kids’ survival”, and the story starts off

Where ambulances take badly injured children first seems to affect their chances, paediatric surgeons say.

Starship children’s hospital surgeons have found that sending badly injured children to the wrong hospital may be contributing to a child death rate from injuries that is twice the rate of Australia’s.

The data:

Six (7 per cent) of the 88 children who went first to Middlemore died, but so did one (8 per cent) of the 12 who went directly to Starship.

That is, to the extent the data tell us anything, the evidence is against the headline.  Of course, the uncertainties are huge: a 95% confidence interval for the relative odds of dying after being sent to Middlemore goes from a 40-fold decrease to a 12-fold increase.  There’s basically no information in the survival data.

So, how much of the two-fold higher rate of death in NZ compared to Australia could reasonably be explained by suboptimal hospital choice? One of the surgeons involved in the study says

… overseas research showed that a good trauma protocol system could cut the death rate for injured adults by 20 to 30 per cent, but there was no good data for children.

That is, hardly any of the difference between NZ and Australia — especially as this specific hospital-choice issue only applies to one sector of one city in New Zealand, with less than 10% of the national population.

On the other hand, we see

The head of Starship’s emergency department, Dr Mike Shepherd, said the major factors contributing to New Zealand’s high fatal injury rate for children lay outside the hospital system in policies such as driver blood-alcohol limits, graduated driver licensing, and laws requiring children’s booster seats and swimming pool fences.

That sounds plausible, but if it’s the whole story you would expect high levels of non-fatal as well as fatal injuries. The overall rate of hospitalisations for injuries in children 0-14 years is almost identical in NZ (1395 per 100 000 per year, p29) and Australia (‘about’ 1500 per 100 000 per year, page v).

Headline:  Study: Dark chocolate calms you down

Lead:

Eating dark chocolate can calm you down according to a new study.

Number of people actually given dark chocolate in the study: 0  (more…)

• From Felix Salmon: US population is increasing, and people are moving to the cities, so why is (sufficiently fine-scale) population density going down? Because rich people take up more space and fight for stricter zoning.  You’ve heard of NIMBYs, but perhaps not of BANANAs
• From the New York Times.  One of the big credit-rating companies is no longer using debts referred for collection as an indicator, as long as they end up paid.  This isn’t a new spark of moral feeling, it’s just for better prediction.
• And from Felix Salmon again: Firstly, Americans are bad at statistics. When it comes to breast cancer, they massively overestimate the probability that early diagnosis and treatment will lead to a cure, while they also massively underestimate the probability that an undetected cancer will turn out to be harmless.

Stuff has a story  (borrowed from the West Island) headlined “Over 40? Five tests you need right now”.

You might have expected some reference to the other recent news about screening: that the US Preventive Services Taskforce has now joined the Centers for Disease Control in recommending universal screening for HIV (as TVNZ reported).  It’s not clear if New Zealand will follow the trend — HIV infection in people not in high risk groups is less common here than in the US, so the benefit compared to more selective screening is smaller here.   This illustrates the complexities of population screening.  Not only does the test have to be accurate, especially in terms of its false positive rate, but there needs to be something useful you can do about a positive result, and screening everyone has to be better than just screening selected people.

So, let’s  compare the suggestions from Stuff’s story to what national and international expert guidelines say you need.

Two of the tests, for high blood pressure and high cholesterol, are spot on. These are part of the national 2012/13 Health Targets for DHBs, with the goal being 75% of the eligible population having the tests within a five-year period.  The Health Target also includes blood glucose measurement to diagnose diabetes, which the story doesn’t mention.  The US Preventive Services Taskforce also recommends blood pressure and cholesterol tests, though it recommends universal diabetes screening only after age 50 or in people with high blood pressure or people with risk factors for diabetes.

One of the tests recommended in the story is a depression/anxiety questionnaire, for diagnosing suicide risk.  Just a couple of weeks ago, the US Preventive Services Taskforce issued guidelines on universal screening for suicide prevention by GPs, saying that there wasn’t good enough evidence to recommend either for or against. As the coverage from Reuters explains, these questionnaires do probably identify people at higher risk of suicide, but it wasn’t clear how much benefit came from identifying them. So, that’s not an unreasonable test to recommend, but it would have been better to indicate that it was controversial.

One more of the tests isn’t a screening test at all — the story recommends that you make sure you know what a standard drink of alcohol is.

The top recommendation in the story, though, is coronary calcium screening.  The US Preventive Services Taskforce recommends against coronary calcium screening for people at low risk of heart disease and says there isn’t enough evidence to recommending for or against in people at higher risk for other reasons. The  American Heart Association also recommends against routine coronary calcium screening (they say it might be useful as a tiebreaker in people known to be at intermediate risk of heart disease based on other factors).  No-one doubts that calcium in the walls of your coronary arteries is predictive of heart disease, but people with high levels of coronary calcium tend to also be overweight or smokers, or have high blood pressure or high cholesterol or diabetes — and if they don’t have these other risk factors  it’s not clear that anything can be done to help them.

As an afterthought on the coronary calcium screening point, the story has an additional quote from a doctor recommending coronary angiography before starting a serious exercise program.  I’d never heard of coronary angiography as a general screening recommendation — it’s a bit more invasive and higher-risk than most population screening. It turns out that the American College of Cardiology and the American Heart Association are similarly unenthusiastic, with their guidelines on use specifically recommending against angiography for screening of people without symptoms of coronary artery disease.

While distracted by a conference in late January, I missed the next exciting installment of the Edinburgh pomegranate saga.

As you will recall, a research group in Edinburgh have put out press releases in recent years about the impact of pomegranate juice on blood pressure, cortisol (a stress hormone), and testosterone.  They haven’t published any scientific papers about these findings, though they have produced a presentation at a scientific conference.

The most recent installment claims that pomegranate extract reduces hunger and food consumption. This study seems to be better designed than the previous ones: participants were randomised to pomegranate extract tablets or placebo for three weeks.  They were then given a glass of pomegranate juice and a meal.  Those who had been taking the pomegranate extract reported feeling less hungry and ate less — 22% less. It’s a pity the study didn’t measure weight, because if the 22% reduction in food consumption generalised beyond the one experimental meal it would have led to measurable weight loss over three weeks.

Again, this was a premature and unsubstantiated press release, and the experiment has not been published in a peer-reviewed journal, although the researchers do at least say they will be presenting it at a conference later in the year.

A long piece in the Washington Post: by Ezra Klein, recommended by Atul Gawande

Brenner puts it more vividly. “There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you’d say, ‘Of course I want that.’ But then you’d say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you’d say, no, you just have to have a nurse come visit her every week.”

• BBC news report on the Amanda Knox case and misuse of statistics: judge did not believe that repeating a test could increase its accuracy (via Mark Wilson)
• A tool for finding stories based on light makeover of press releases. Unfortunately, it often doesn’t detect recycling of stories from sites such as Medical Daily and Science Daily, which do enough rewriting to mask the sources.
• New York Times opinion piece on evidence and science reporting — yes, distinguish experimental and observational studies, but also distinguish small exploratory studies from larger confirmatory ones. (via @brettkeller)
• Using anecdotes rather than data to convince patients. On one hand, speaking to people in language they understand is good; on the other hand, you can use anecdotes to support anything.

The New York Times has a story about finding interactions between common medications using internet search histories.  The research, published in the Journal of the American Medical Informatics Association, looks at search histories containing searches for two medication names and also for possible symptoms.  For example, their primary success was finding that people who searched for information on paroxetine (an antidepressant) and pravastatin (a cholesterol-lowering drug) were more likely to search for information on a set of symptoms that can be caused by high blood sugar.  These two drugs are now known to interact to cause high blood sugar in some people, although this wasn’t known at the time the internet searches took place.

This approach is promising, but like so many approaches to safety of medications it is limited by the huge number of possibilities.  The researchers knew where to look: they knew which drugs to examine and which symptoms to follow. With the thousands of different medications, leading to millions of possible interacting pairs and dozens or hundreds of sets of symptoms it becomes much harder to know what’s going on.

Drug safety is hard.

Two opportunities for public comment that will expire soon, and where StatsChat readers might have something to say

• Stats New Zealand wants to hear from people who use Census data.  They have a questionnaire on how you use the data, and how this might be affected if they change the Census in various ways. It’s open until Friday May 3
• Public submissions on the new ‘legal highs’ bill close on Wednesday May 1.  The bill is here. You can make a submission here.  The Drug Foundation have a description and recommendations here. 

This sort of public comment is qualitative, rather than quantitative.  Neither the Select Committee nor Stats New Zealand is likely to count up the number of submissions taking a particular view and use this as a population estimate, because that would be silly.  What they should be aiming for is a qualitatively exhaustive sample, one that includes all the arguments for or against the bill, or all the different ways people use Census data.

• Martin Johnston in the Herald on a nationwide blood pressure survey. Blood pressures are up.  This is not good.
• Nikki Macdonald in Stuff, on recreational genotyping (or as the story more properly calls it, “direct to consumer” genotyping).