Monday, October 20, 2008

** Worried Sick by Nortin Hadler MD

Another doctor in the less is more camp. Hadler exposes some of the myth around treatment – especially surgical procedures and pharmacological treatment has just has not proven itself to be markedly better than no action or no action coupled with low cost treatment – such as eating a baby aspirin. He basically states that yes, we get old and eventually die, so get used to that fact. Medicine should work first to help us live as well as we can up to a reasonable age of 85 for most of us, realizing fully that even prior to that age, biological systems in our body will start to fall to pieces, and that is perfectly normal. Death is not a disease, it is a normal biological act. If you are a skeptic, this book will only harden your skepticism. If you’re not a skeptic, perhaps this will help you develop a bit of healthy questioning for your physician to ponder.

Angioplasty: case closed

A VA trial of 2000 heart attack patients had ½ receive angioplasty with a stent, and ½ not. The stent therapy did not save a life; it didn’t even spare anyone a heart attack over the next five years. The studies conclusion was that angioplasty ‘did not reduce the risk of death, heart attack, or other major cardiovascular events’ p26


Angina: is it all in your head? 

Trials of invasive procedures (surgeries) require sham controlled trial (with an actual surgery). Sham surgery trials where ½ the subjects experienced symptomatic relief whether in the sham or the putatively effective groups? That is generally the result of 1000s of placebo-controlled, randomized trials of pharmaceuticals for angina. For agents that pass regulatory muster, the effectiveness was a bit more than the 50% response rate found in the placebo group. Does this mean that angina is ‘in your mind’?... Maybe participating in a trial where you might be afforded benefit helps deal with the anticipation of the pain more effectively or allows you to circumvent precipitating angina by subtle alterations in behavior. Those are plausible forms of ‘in your mind’. For me this is reasonable enough as an explanation for the time being. P28


If you have transient ischemic attack (TIA) – a small stroke with reversible neurological deficits – and an occluded carotid artery feeding the side of the brain that is suffering the stroke, surgical removal of the plaque will afford you a meaningful reduction in your risk of suffering a stroke on that side – meaningful enough to justify the surgical risks, which are substantial. But that surgery will not improve your longevity: you are likely to die at the same time, often of stroke on the other side or of cardiac disease. P29


Angioplasty/stents: case is still closed

A large trial comparing stenting with carotid plaque removal surgery (mentioned above) had to be stopped because there were fewer deaths and strokes with carotid surgery than with stenting. There are several other trials under way using different stents and different techniques, all trying to match carotid surgery – which itself is damn near useless. P30


If one suffers a stroke, and undergoes a cerebral angiogram (a catheterization of blood vessels) within 3 hours, and has a blockage from a blood clot, then infusing drugs infusing drugs directly into the artery to dissolve the clot improves the likelihood of a more complete recovery. That assumes that you are not in the 6% of cases where infusion of the anti-clotter causes far more catastrophic than the stroke itself. I’ll take my chances with natural history and an aspirin. If stroke is my fate, it is far more likely to be mild, and to occur near my 85th birthday. P30


All tests for angina from exercising while monitoring your EKG to exercise tests that more directly monitor the perfusion of your heart muscle – are not up to making the diagnosis of angina or excluding it either with compelling validity. P32


Only 1 to 2 years is all it costs? Pass the bacon!

If you have no extraordinary family history, yet have you very high LDL and low HDL cholesterol, it will cost you 1 to 2 years of life expectancy. Nearly all who are labeled high cholesterol are far from the extreme and have minimal risk. Nearly all labeled ‘high cholesterol’ are contending with a reduction in life expectancy of months. Do you think a reduction of months in life expectancy is meaningful, or even measurable? P34


There’s no question that the ‘statin’ family of drugs can lower cholesterol… However there is a serious question as to whether statin treatment affords any meaningful advantage to those of us who have not suffered a heart attack. Are statins useful for the prevention of heart disease?... The landmark 1995 study published in the New England Journal of Medicine stated that ‘Deaths by Heart Attack’ was reduced by .6% That difference is barely statistically significant; it would happen 4.2 times out of 100 by chance, slightly less than the cutoff for significance of 5 times in 100. p35


Baby aspirin is not just for babies

The likelihood of surviving for 5 years after your 1st heart attack is 95%. If you take a baby aspirin daily, it rises to 97.5%. That’s a 2.5% absolute risk reduction, but a 50% relative risk reduction… If you have a heart attack, it makes sense to take a baby aspirin daily for the rest of your life. But should a person who has never had a heart attack do the same? The absolute risk reduction for the primary prevention of heart attack is miniscule. The good news is that the risk of intestinal bleeding is also miniscule. It’s your call. P37

Fishy conclusions about a fishy diet 

The dearth of atherosclerotic disease among Eskimos and Japanese and the fact that their diets are rich in seafood, was held up as more than just coincidence. No ones seems concerned that these are genetically distinctive populations living in countries with distinctive socioeconomic structures. The notion of eating fish or olive oil or more vegetables, or less meat or whatever promises the fountain of youth – easily gain credibility. To test the inference with a randomized controlled trial seeking differential effects on important outcomes in a well population is prohibitive. Can you imagine controlling the diet of ½ of the sample for decades, and waiting to see how many die and how? Even modern epidemiology has no such hubris… Take for example the famous Nurses Health Study started in 1976 until 1994 measuring over 120,000 nurses. During this period there were over 500 deaths ascribed to heart disease, and 1000 non-fatal heart attacks – that equates to only .5% death rate, and 1% had suffered a non-fatal heart attack. Even if every one of these 1500 women avoided fish (unlikely), and the remaining 98,500 women ate fish often (again, unlikely), you’d still be skeptical that eating fish can save lives because you’d wonder what else was going on that you weren’t measuring. P60


Are transfat really proven to be that bad? 

Trans fat are new demons of the food kingdom. How did that come to pass? From the Nurses study. There was a 33% relative risk increase based upon a tiny number of nurses whose dietary intake over 2 decades is at best approximated… Do you really think any of us can recall our dietary intake last year with the exactitude prerequisite to the analysis? P62


Want to get rich? 

“There’s a $1000 bill in every American rectum; you just have to get up there and get it.” How British doctors views the American medical system’s handling of colon care. P67


The 60/40 about 50

About 1% of people over 50 have at least 1 polyp, and the population acquires polyps at the rate of 1% per year after age 50. We also know that age 50, you have a 2% chance of dying from colon cancer over the next 30 years. You also have a 60% chance of dying from all causes over the next 30 years; or that is saying you only have a 40% chance of making it to your 81st birthday. Suppose you reduce a person’s relative chance of dying of colon cancer after age 50 by 60%. This means your 2% chance of dying from colon cancer is now .8%, but you chance of dying from all other diseases is not meaningfully reduced. P70


Breast cancer screening facts

A Canadian trial enrolled 50,000 women age 40 to 49, and 39,000 women age 50 to 59 between 1980-85. All were examined and then instructed how to perform breast self examination. They were then randomized to a group annual given an mammogram, and those who were not screened. There were 3 telling observations:

1) 213 of the 40 to 49 year olds had died of breast cancer, and the deaths were distributed equally amongst the mammography and non screened groups.

2) There were 107 deaths by breast cancer in the 50-59 group who received mammography, and 105 in the non-screened group.

3) Based on these data several – but not all – North American medical bodies have backed down from recommending mammographic screening in women aged 40 to 49. p90


To be screened or not be screened? That is the question that Hamlet should have asked. 

Almost 90% of male physicians aged 50 and older, and nearly all urologists have had a PSA (I have and all is well thank goodness). The author, who is a physician over age 50 will not consent to a PSA, let alone a rectal exam. Here’s why. Screening is defensible if most, if not all, of the following goals are met. 1st screening must detect something that is meaningful to me, 2nd it must be efficient in the sense that it has few false positives and negatives. And 3rd, if a true positive is detected, something meaningful can be done about it. Screening for prostate cancer fails on all counts. P96


No one should think that surgery will vanquish their risk of death from prostate cancer; it will only reduce it by half. And no one should think that surgery will increase your lifespan; it will only change the cause of death. P99


The cure is worse than the disease

15% of those who undergo prostatectomy will have to cope with incontinence by wearing a diaper. That’s a catastrophe for most. 30 % of men will be afflicted with erectile dysfunction, leading to distressed intercourse. That is a catastrophe as well… The men who forgo surgery are not spared, but rather suffer from obstructive symptoms impinging urine flow. P99


Prostate surgery might be worth it if you're under 65

After 10 years, 8.6% of men who had prostatectomy had died of cancer compared to 14.4 in the watchful waiting group. However overall mortality was 24% in the surgery group vs. 30% in the waiting group. There is then a suggestion of meaningful survival benefit of surgery in men younger than 65. p100

Knee jerk surgery?
Arthroscopic surgery for knee pain has been debunked in a randomized, controlled study published in the NE Journal of Medicine suggesting that you would be WORSE off for that effort. Glucosamine/chondrotin concoctions are marginally useful at best in studies paid for by their hawkers… Total knee replacement is neither a replacement nor an appealing option. Few enjoy the dramatic pain relief that those with hip replacements often revel in. P119

Let nature take care of the pain in your neck
If you neck pain be wary of vertibular surgery. This surgery is based upon theory that has never been put to the test, and is based upon extrapolating surgical outcomes for low back (sciatica) pain, that showed that surgery provided some additional relief (not much) compared to the natural rate of healing. P120

Is it better than aspirin?
The following is true of every NSAID that has ever been approved:
1. It has been shown to be more effective than placebo
2. None have been shown to be LESS or MORE effective than aspirin
3. None have been shown to be SAFER than aspirin p125

Living the high life?
25% of us frequently experience alternating diarrhea and constipation, but very consider this worrisome. As many as 20% of us find our joints stiff for 30 min or more without finding that bothersome… 5 to 15% of people are coping with being out of sorts (pain, fatigue, GI distress, etc). Most perceive themselves as no longer well, and they are particularly likely to see medical care repeatedly. P136

A bone to pick
Our bones continue to grow in fine structure, gaining mineralized matrix well into our 3rd and 4th decade…. There is a positive influence of moderate weight bearing exercises on the degree of mineralization and a negative influence of being too thin (low weight) and of smoking… In our 5th decade we slowly come to lose our bones via demineralization. This is normal. P155
Hey pinhead, acupuncture is all in your head!
Patients were saw an acupuncturist twice weekly for 10 sessions. ½ were given sham acupuncture with a sheathed needle. It looks and feels like the real thing, but never pierces the skin. Everybody improved in both trials… Further, a placebo was compared to sham acupuncture which improved pain at a faster rate than the placebo. A placebo pill is no match for the acupuncturists treatment act: the rituals, the beliefs, the body language the explanations, and whatever else went on even though the needle never pierced the skin. P195

The less than 2% solution
Here’s a partial list of treatments that would not qualify that would not benefit 1 in 50 people who are treated:
Coronary bypass, angioplasty, stents, arthroscopic knee surgery, any surgery for backache, statin therapy to reduce cholesterol to save lives, newer antidepressants for situational depression, PSA screening and radical prostatectomy to save lives, screening mammography to save lives, many a cancer treatment to save lives.

Only 25% of the hazard to longevity resides in the proximate cause of death (Lantz et al 1998)… and the lack of healthcare accounts for only 10% of our mortal hazard (Schroeder 2007). P231
615 coronary events occurred among 13,000 study participants. The poorest whites were 3 times more likely to be afflicted than the richest whites; for blacks this hazard ratio was 2.5. p232
People of low socio-economic status (SES) who resided in wealthier neighborhoods had a higher mortality risk than people of low SES who lived in poor neighborhoods… It turns out that social hierarchy influences the health of primates, including humans. It other species, it can be shown that low ranking in a dominance hierarchy associates with numerous adverse biological outcomes.


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