Margaret McCartney's Blog, page 9

New things – are children unhealthily dehydrated?

I don’t think so. Riposte to Nestle’s press release here in the BMJ and a tiny piece about the DoH and Telehealth here 

 

 

Lifeline Screening advert withdrawn. Hurrah. But what will they replace it with….

After almost 11 months  the Advertising Standards Authority have decided that Lifeline Screening (you know, the ones that run full page, scaremongering, alarmist, and highly biased adverts in the press encouraging people to have non evidence based screening tests in their church hall for 100 quid upwards) must change their adverts. I was not the only complainant – David Nicholl, consultant neurologist, and Professor Charles Warlow, ermeritus professor of neurology, complained too (and you can some of their writings about Lifeline here http://www.bmj.com/content/338/bmj.b1940 and in a response to an article about screening companies I wrote for the BMJ here http://www.bmj.com/content/344/bmj.e2311.full?ijkey=OzLHzO5gq7L7wZK&keytype=ref. )

My complaints were several; the bottom line is that these screening tests are oversold, underexplained, without decent information about the uncertainties and potential harms. I’m glad that the ASA have agreed that the adverts should change. Because Lifeline have agreed to make changes, this is not be a formal adjudication and therefore the details will not be published on the ASA website. However (see blog below) the ASA have stopped asking people to retain this information in confidence.

This is important; if you are thinking about having one of these tests, I think it’s useful to know that the company have had their adverts complained about by doctors who were very concerned about their evidence, and were withdrawn on this basis.

There are bigger questions for doctors. Lifeline Screening has a medical director. The GMC says that you should “provide effective treatments based on the best available evidence” and that you should  ”share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression, and the treatment options available to them, including associated risks and uncertainties”. Do these adverts fulfill these needs? I don’t think so. However, the GMC need evidence of harm to act.

So if anyone has been harmed by these adverts or the screening tests, you might want to let the GMC know.

I will be watching for their next adverts with a critical eye. If you want to know more about screening tests, this booklet from Sense about Science is a good place to start.

ASA – change to ‘confidentiality’ policy

I am very very pleased to say that Lord Smith, as Chair of the ASA, responded remarkably quickly to an email I sent raising concerns with their policy. Previously, in ‘informally resolved’ complaints, the ASA has asked complainants to treat the judgement in confidence. I was unhappy; this seems to protect the company, not the customer. So I am delighted that this policy is now stopped. Letters to complainants from the ASA regarding informally resolved complaints will no longer ask them to keep the contents ‘confidential’.

Very pleased indeed.

A reading list for media doctors who would like to know more about screening.

 

How to Read a Paper by Trisha Greenhalgh Much is in the BMJ, if you already subscribe.

Screening; evidence and practice. Muir Gray and Angela Raffle.

Testing Treatments, also from Pinter and Martin, and available freely online here.

Overdiagnosed, by Welch, Schwartz and Woloshin.

Fooled by Randomness, by Nassim Nicholas Taleb.

The Tyranny of Health, Michael Fitzpatrick.

Reckoning with Risk, Gerd Gigerenzer.

Matters of Life and Death, Iona Heath.

The Lancet series on treating individuals.

Should I be tested for cancer? Maybe not and here’s why. Gilbert Welch.

Also two things from Sense about Science – making sense of testing and making sense of screening , both free, both which I helped with

There’s my book, natch (which is cheaper from the publisher)  - The Patient Paradox.

I also suggest going to a course on evidence based practice via the Centre for Evidence Based Medicine in Oxford. I did a couple of years ago and it was excellent.

Then there is EvidenceLive 2013, where all kinds of evidence based people will be talking (including me).

And where I am willing to buy any famous media doctors a drink if they want to come and listen.

 

 

 

 

 

The 3 week cough campaign

and my concerns about it’s effectiveness and potential harms.

References here.

1)     http://www.3weekcough.org/whattodo.html

2)     Lung C ancer Awareness Campaign Cluster Briefing Slide Pack, 2/4/12, DoH

3)     http://thorax.bmj.com/content/67/5/412.long

4)     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1747254/pdf/v060p01059.pdf

5)     http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1747254/pdf/v060p01059.pdf

6)     http://thorax.bmj.com/content/61/11/975.abstract

7)     http://thorax.bmj.com/content/61/11/975.abstract

8)     http://www.ncbi.nlm.nih.gov/pubmed/16882373

 

Self checking via Embarrassing Bodies

I’ve just watched an episode of this Channel 4 programme.

Who can forget Dr Chris Steele doing the ‘first’ (!) testicular check on TV.

And now we have had the Embarrassing Bodies, the Channel 4 programme, providing us with more of the same.

It’s very tempting to think that more ‘awareness’ is always good for us, and it’s also easy to conclude that therefore, these programmes are good for us.

I’d disagree. We know that the problem with testicular cancer is NOT men being unable to find lumps, but in delaying seeking help with they do. We could speculate why, but small qualitative studies make clear that many men are frightened. That’s why it’s important that it’s clear to men that most testicular lumps are not cancer; testicular cancer is very treatable; hence prompt attention is needed to any new lump. Proper ‘awareness’ should include fair information which gets facts over, not fear about a cancer that might not be detected without the ‘right’ self examination skill.

We  know from other similar ‘awareness’ interventions that they can increase health inequalities. Broadly, the least unwell, or least at risk of being unwell, get more attention than sick people. These kind of campaigns don’t often deliver to the people they are potentially most able to help.

We also don’t know that teaching men to do testicular examinations, in a formal way, is helpful. It’s not good enough to assume that it must be – there is good evidence that teaching women breast self examination does not reduce deaths from breast cancer, and it does harm, through generating more benign biopsies.

The new feature on the Embarrassing Bodies website is a ‘self checker’. There is a video on breast examination recommending monthly breast checks, and telling you how to do it, another video saying “how important it is to self-check your vulva”. Then there is a urine test, when yellow urine is declared “darker than normal which could be a sign of dehydration” . There is also the PHQ-9 Pfizer-owned tickbox test which apparently will “provide you with an indication of your risk of suffering from depression” ; even though there is no evidence that this will be useful in normal risk people. The risk screening tool used to ‘evaluate your risk of chronic renal disease’ is based on data used in high risk individuals, and, if you say, like many women, that you’ve a history of anaemia, and don’t know your blood pressure or whether there’s protien or not in your urine, the result is “it’s important that you get yourself checked out by your GP”.

I think it’s a good idea for people to have good information about their health. But it’s unfair to put insufficiently explained tests, or tests of unproven effectiveness up on their website and expect the NHS to cope with the fallout.

The things to do to keep healthy have hardly changed in the last 20 years. Don’t smoke, don’t drink  excessively, eat a variety of foods, mainly plants, keep to a reasonable weight, do some exercise you like, and I’d add, meet people and do things you enjoy. That doesn’t include healthy people being taught to do regular self examinations or online questionnaires.

Fish oils for mental illness: don’t waste your money.

And more than that, concentrate  efforts on things that are more likely to help now and in the future.

I’m disturbed by the idea that fish oils are a  good idea for ‘depression to schizophrenia’ as evidenced by this article. There are several reasonable theories as to why fish oils might help mental health, but the problem is that theory is not enough. The history of medicine is littered with great ideas that did harm or no good.

The best way to get a handle on what the studies show is to read the evidence, all of it. This would take a very long time. The additional problem is that trials showing a benefit are more likely to be published, and to be publicised, than trials showing they don’t work. So you have to dig deep, and the best and fairest way is to look for Cochrane reviews. These are reviews of all the evidence on the subject, and pull together all trials – not just tiny trials that were positive and gained a lot of coverage – but also negative trials.

Cochrane is pretty clear.

For schizophrenia, they say the evidence is “inconclusive”.

For bipolar disorder, there is “insufficient evidence”

For borderline personality disorder, “Total BPD severity was not significantly influenced by any drug”

I can’t find a Cochrane review for the effects of fish oil on unipolar depression, but this review suggests that the possible helpful effects are “potential” only, and needs proper trials. A previous systematic review had found “little support” for fish oils in depression.

And while we’re here, a reminder that Cochrane have also said that “ there is no good evidence to support the use of dietary or supplemental omega 3 PUFA for the prevention of cognitive impairment or dementia”.

It would take me time I don’t currently have to go through the rest of the article.

It’s easy to be sold the idea that the solution to hard problems can be delivered in a pill. Many medications do have a useful and important role to play in treating mental illness. But many do not, and just because something is ‘complementary’ (i.e. not proven to work) does not make it safe. It also serves to distract us from the things that do matter, and it means that we are pushed to a dichotomy in the evidence for what we take – one standard for prescribed drugs, another for what we buy. We should be demanding high quality evidence for both. That’s why I don’t recommend fish oil supplements to  people who have mental health conditions.

minor success

Sanctus clinics Edinburgh are no longer offering non evidence based ‘breast checks’

and

Champneys are no longer offering non evidence based ovarian cancer screening.

It would be very good if Champneys would now get rid of the rest of their enormous lot of non evidence based screening tests.

There are loads.

Do let me know, Champneys.

The rise of the pop psychologists

link to BMJ piece here

BMJ – that breast cancer blood test story

…is analysed here. (free link)

There is also a piece about Breastlight at Pulse (free with free registration.)

 

and here’s the link to today’s ASA page where PWB health, who make Breastlight,feature.  feature.

 

Their website doesn’t say ‘detects cancer early’ anymore. But I’m still not happy.