Monday, 12 November 2018

Should we statinize society?

A 2011 Cochrane review concluded that there was not enough evidence to prescribe statins for people with a cardiovascular risk of less than 20% in 10 years, a claim that was consistent with the British NICE guideline (2006-2008) and with the American Heart Association (2011). The surprise came when, unexpectedly, the 2013 Cochrane review changed its mind and lowered the statin threshold to the 10% risk at 10 years, a recommendation that was quickly adopted by the NICE guidelines.

Strongly opposed to this change of approach, John Abramson (Harvard Medical School), and collaborators, in "Should people at low risk of cardiovascular disease take a statin?" ensure that with the criteria of 2011, in the population over 60 years, it would have been necessary to statin 16% of women and 48% of men, but with the recommendations of 2013 the market was extended to practically all the population of older people, given that age is the most influential cardiovascular risk variable in risk calculators. The authors have reviewed the meta-analysis that led to the change of criteria ("The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomized trials") and have reached conclusions that contradict the Cochrane recommendations of 2013:
  1. Of every 140 low-risk people who take statins for 5 years, only one will benefit from avoiding a myocardial infarction or stroke.
  2. 20% of people who take statins have adverse effects, some of them considered as myopathies or diabetes.
  3. In people of low risk, the use of statins implies a small improvement in the reduction of vascular complications, without translation in mortality, which doesn’t compensate the extent of the undesirable effects.
  4. Physicians should forget statinizing people at low risk and should, instead, focus on the lifestyle factors (exercise, smoking and diet) of their patients, which accumulate 80% of the risk.

At the "Preventing Overdiagnosis" Congress (2017), Abramson and two of his collaborators, Rosenberg and Wright, organized a workshop where they shared the update of their work on the medicalization of cardiovascular risk prevention. From the researchers’ explanation, I have prepared a compilation in four points, which I think contribute many elements in such a key debate about the excesses of the medicalization of people's lives:

a) Older people have a more or less long life regardless of their cholesterol levels. A systematic review has shown that in people older than 60 years, the LDL cholesterol level is inversely related to mortality. This finding dismantles the cholesterol theory.

b) The accuracy of the risk scales has been poorly evaluated. It’s thought that calculators tend to fall short in the high risk groups and long in the low risk groups. Clinicians should know the limitations of the measurement instruments they use.

c) There’s no absolute finding that the systematic practice of cardiovascular risk assessment improves clinical effectiveness.

d) Contrary to current belief, the relative benefit that statins can provide is not a constant that affects all people equally. The level of risk, age and gender vary its effects.

Medicalising high-risk people is an initiative that, according to the evidence, can bring a lot of value, but the recommendations to lower both the risk threshold, with such a scarce scientific support medicalizes in an inadequate way to many people, when in fact what they should to do is to go more to the greengrocers, to the gymnasiums and promote a positive spirit towards life.

As Margaret McCartney says, people decide things, apart from planners, for many reasons. Many stop taking statins because of the adverse effects they notice, or simply because they get tired, others reject the proposal because they are not in favour of thinking in terms of avoiding long-term risks, while some claim them, want maximum security, on the margin of their risk levels.

However that may be, let’s not forget that adherence to statins reaches barely 50% per year and, among those over 65, to 25% after two years: a clear reflection of the disagreement between the clinical practice guidelines and the value that patients give to their doctors’ advice.

Jordi Varela

Monday, 5 November 2018

Reflections on precision medicine

Precision medicine, or personalized medicine, is an initiative of the US government that aims to adjust, according to individual characteristics, the prevention and treatment of diseases with genetic, phenotypic, clinical, environmental and lifestyle data. For this reason, the federal government, through the National Institutes of Health (NIH), is financing projects to sequence more genomes, create large bio-banks and generate big data studies from electronic medical records and all types of electronic devices of diagnosis and monitoring (for more information we advise you to visit the post of Cristina Roure on the subject).

Monday, 29 October 2018

Innovation 3.8 over 10: a clear "not passing"

Josep Mª Monguet

Self-deception is the path to regression. A few years ago (in 2006), I was invited to speak at the opening course conference for one of the entities of my university. I spoke about the deficit in innovation observed in Spain, sustained by multiple data. The rector, who spoke later, did his best to deny it using the sole argument that the universities had a large scientific production [1]. It became clear that he didn’t understand the difference between innovation and academic scientific production. Well, ten years later, our country is still the same if not worse. We can continue doing nothing about it, but we must understand that for building an innovative country, the islands of excellence are essential, but not enough.

Monday, 22 October 2018

Non-pharmacological prescription, the first choice treatment

Cristina Roure

Regular physical activity, directed exercise, social prescription or cognitive therapies don’t perform miracles, but neither do the medications that are prescribed daily in consultations and instead we accept them as a necessary evil, allocating 1 in 5 euros that is spent on health to pay for medicines that are not always taken, that don’t always produce the expected benefits when they don’t cause more harm than good.

Surprisingly the medical community find it hard to accept the role that non-pharmacological interventions and particularly physical activity should have not only in the prevention and treatment of chronic diseases, but also to combat frailty in an aging population like ours which moreover, lives submerged in a lifestyle that, after the incessant search for comfort, avoids any effort.

Monday, 15 October 2018

Break the "ill-fated trio": falls-immobility-delirium, an outstanding issue in the quality of hospitals

Marco Inzitari

The pressure on the safety of patients and medical errors to which we are all subject, together with the fear of professionals for possible complaints resulting from adverse events within the hospital (Hospital Acquired Conditions - HAC, for Americans), are changing the hospital culture, prioritizing the prevention of falls, in many cases, on top of mobility, functionality and, finally, the well-being of patients.

This is what happened in the US from 2007-2008, when the Centre for Medicaid and Medicare Services decided to penalize the billing of episodes of patients affected by different HAC, including falls with injury, to the Affordable Care Act (Obamacare), which penalizes hospitals with worse results in this sense. In our context, in recent years some care areas have also been rewarded or penalized, at the contract level, according to an indicator of intra-hospital falls.

Monday, 8 October 2018

The laws of medicine

Siddhartha Mukherjee, oncologist, researcher and professor at the University of Columbia, is the author of a small essay, The Laws of Medicine: field notes from an uncertain science (2015), which I found interesting enough to recommend to clinicians who desire to think a little more about what they do. "In the medical school," says the author, "they taught me a lot of facts, but they did not prepare me to navigate the immense spaces between these facts. Right now I could write a thesis on the physiology of sight, but I feel lost when I try to understand the conniving network that makes a man, who was prescribed home oxygen, give a false address to the service providers, embarrassed (I later learned), because he lived on the street."

Wednesday, 3 October 2018

Social addiction to biometrics

Salvador Casado

Mirrors are polished surfaces that reflect the image projected on them.  It is a technology that the ancient Egyptians and Greeks already knew and that has evolved over time. Today the majority of the population carries a pocket mirror that also allows immortalizing the images that come to it in the form of an auto-photo. In addition, modern mirrors reflect multiple variables and information of their owner. They measure his steps and the distance he travels, his activity pattern, his movements, his level of communication. They can measure the sleep/wakefulness rhythm and give a report on the quality of sleep and if we connect some specific gadget they can measure blood pressure, blood sugar and even do an electrocardiogram.