Does self building improve health?

[Jeremy Harris]

11 minutes ago, SteamyTea said:

One of the problems of that class of drug is that it is not affective in all people.  Estimates of effectiveness range between 0 and 70%.  This is a case of very bad medical practice.

 

Here's the Cochrane evidence for Fluoxetine (Prozac^TM) :http://www.cochrane.org/CD004185/DEPRESSN_fluoxetine-compared-with-other-antidepressants-for-depression-in-adults?o=prozac

 

For those that can't be bothered to read the link, these are the authors conclusions:

 

Quote

Authors' conclusions: 

 

The present study detected differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain. Moreover, the assessment of quality with the risk of bias tool showed that the great majority of included studies failed to report details on methodological procedures. Of consequence, no definitive implications can be drawn from the studies' results. The better efficacy profile of sertraline and venlafaxine (and possibly other ADs) over fluoxetine may be clinically meaningful, as already suggested by other systematic reviews. In addition to efficacy data, treatment decisions should also be based on considerations of drug toxicity, patient acceptability and cost.

 

[newhome]

5 minutes ago, Onoff said:

My old GP was an absolute star!

 

 

Lol. Presume they kicked him into touch? 

 

 

[Ferdinand]

6 hours ago, JSHarris said:

 

Take a look at the work being done by Cochrane (http://www.cochrane.org/ ).  Much of it highlights just how dire a great deal of medical research is.  One could be forgiven for thinking that medical researchers had never heard of the scientific method, their work is so appallingly bad. 

 

It's not just research either, a lot of the measurement methods used every day in medicine are really poor.  Blood pressure is a really good example.  The actual measurement equipment and the technique, be it auscultation or oscillometric, is reasonably good, and probably has a repeatability and accuracy of around +/- 5mmHg, but there are large errors introduced by the way the patients arm is held, the height of the cuff relative to the heart and whether the measurement is made on the dominant or non-dominant arm.  These variations are enough to make the difference between someone being diagnosed with high blood pressure when it's really normal, or someone with high blood pressure not being diagnosed at all.  Add in that around 20% or more of the population will appear to have elevated blood pressure when it's measured in a clinical environment ("white coat hypertension") and that the accurately measured effect of even the very best anti-hypertension drugs is similar to the normal measurement error in magnitude, and this whole area of health care starts to look very dodgy indeed.

 

As someone who has regular bop measurements, there has been a noticeable move back to traditional pump bulb over tech pump methods for measuring bp amongst practitioners. 

[newhome]

1 minute ago, Ferdinand said:

 

As someone who has regular bop measurements, there has been a noticeable move back to traditional pump bulb over tech pump methods for measuring bp amongst practitioners. 

 

I think it depends. They still use tech pumps at my GP practice mostly but when I had an op on my knee recently they used the pump bulb. I asked why and was told that patients preferred that method to a machine tightening the cuff and causing discomfort. 

[joe90]

Some people can’t handle the truth, I like doctors like that myself.

[Jeremy Harris]

40 minutes ago, Ferdinand said:

 

As someone who has regular bop measurements, there has been a noticeable move back to traditional pump bulb over tech pump methods for measuring bp amongst practitioners. 

 

I have a vested interest in the bad evidence for hypertension, as I was "diagnosed" with it over 30 years ago, during an annual aircrew medical.  I was sent to see my GP, who then referred me to a consultant, who did a whole barrage of tests and could find no underlying cause, so gave a diagnosis of "essential hypertension" (in essence, "we have no idea why your blood pressure seems high, so this is the name will give it").  I was put on various hypertension medications over the years, some of which had unpleasant side effects (and one indirectly led to me losing a tooth).  I ended up taking an angiotension receptor blocker (ARB) for several years, as these had the least noticeable side effects.  Having hypertension doesn't often have any noticeable symptoms, but I noticed that on the rare day when I forgot to take a pill, I could tell by around lunchtime, as I seemed to have a lot more energy.

 

I mentioned this to my GP and he didn't really take much notice (but, to be fair, he was on run-down before taking early retirement).  I had also mentioned to my GP several times over the years that my home BP measurements were, if anything, on the low side, and went so far as to keep sending him printouts from an Excel spreadsheet before every annual medication review to prove this.  

 

As I wasn't exactly happy at my GPs attitude, I went and found out about Cochrane late last year and read every single review they had conducted.  The first shock was to find out how relatively ineffective anti-hypertension drugs are (at best they reduce BP by around 10 to 15mmHg, often less).  Based on the collected evidence presented by Cochrane I decided to ask my GP if I could have a 24 hour ambulatory blood pressure monitor test, as the Cochrane evidence was clear that no diagnoses for hypertension should be made without one (bit late after 30 years of taking pills, though!).  He said they hadn't got a machine available, so I decided to buy one, despite the high price, as I was determined to find out what was going on.  I did two separate 24 hour ABPM sessions, one mid-week, when I was working, one on a Sunday when I was relatively sedentary.  Both sets of data were very similar, and showed my BP to be low. 

 

As I was fed up with my GP. and he was retiring anyway, I decided to halve the daily dose of the ARB I was taking, wait a couple of weeks and do another 24 hour ABPM session.  That showed my BP was the same as on the full dose.  I then just stopped taking the medication altogether, and a couple of weeks later did two more 24 hour ABPM sessions, which showed my BP to be slightly lower than normal and well below the stage where treatment was needed.  One side effect was that I had loads more energy and generally felt a great deal better.

 

By this time a new GP had replaced the one I'd been seeing for over 15 years.  I was due for a medication review, and wanted to cancel my long-term repeat prescription, so I armed myself with all the Cochrane evidence, my home BP readings going back for the past few years and the results from all the 24 hour ABPM sessions, then went to see her.  She looked at my records, looked at the file I'd given her, then said that I should never have been diagnosed with essential hypertension as it was very clear that all I had was "white coat hypertension", something around 20 to 30% of people have, where their BP is elevated when measured in a clinical environment, but normal when measured at home.  She apologised on behalf of the NHS for the 30 years of treatment I'd put up with, the slight harm this had caused and she stated very clearly that her predecessors had failed to do proper diagnostic checks before just prescribing me medication that I did not ever need.

 

Even now, several months later, it still seems odd not taking a pill every morning, but I feel a lot better overall for not taking the damned things.  I do still feel angry that the calcium channel blocker that I was originally prescribed, and which I took daily for over ten years, caused my gums to swell which then resulted in gingivitis, moderate gum erosion and the loss of a tooth.  I also feel angry that after that episode (which at the time I hadn't realised was due to a drug side effect) I was prescribed an ACE inhibitor, that had the nasty side effect of causing perennial rhinitis, that at the time I just thought was hay fever, or an allergy.  Thankfully my old GP did pick up on that after a couple of years of me suffering from it, and changed me on to the ARB , to control my non-existent hypertension, and all they did was cause me to feel a bit fatigued.

 

Overall I'm bloody angry at 30 years of mistreatment, with associated side effects, more than a bit of worry and stress about something it turns out I never suffered from, not to mention the cost to the NHS (and my wallet) from all those prescriptions that weren't needed.  Do I trust my GP now?  No, to be honest I no longer do.  From now on I will question and independently check anything any doctor says to me.

[jack]

9 minutes ago, JSHarris said:

From now on I will question and independently check anything any doctor says to me.

 

I always, always do this now. It's not that I don't trust them, but GPs are expected to have such an incredibly wide range of knowledge that it isn't surprising that they aren't perfect.

 

Trust, but verify!

[SteamyTea]

1 hour ago, Onoff said:

My old GP was an absolute

Murderer

This is my old GP

https://www.independent.co.uk/news/voices-in-doctors-head-told-him-to-kill-daughter-1574679.html

[newhome]

22 minutes ago, JSHarris said:

From now on I will question and independently check anything any doctor says to me.

 

I have always verified anything I have been told medically. I never take any drugs or have anything done without researching it to death and asking lots of questions. I will look at YouTube videos of any surgeries I have so that I am absolutely clear what will be done and so that I can ask lots of questions. I’m sure I’m a nightmare lol. 

 

In the UK we do have pretty amazing emergency medicine however. I ended up in ITU for 3 weeks on a ventilator in an induced coma a few years ago. There is absolutely no doubt that the treatment I received was life saving. I’d had the flu, thought that I would shake it off but didn’t, and I was probably as near death as you can be without being dead, as I’d started to go into total organ failure and my oxygen levels were so critically low they weren’t sure how I was still conscious. So whilst we criticise the health service, and there is good and bad for sure, I am thankful that they were there at that time. And you can have as many PMI policies as you like but they don’t cover emergency medicine. 

 

 

 

 

[Jeremy Harris]

@jack, you're right, there's no way that a GP can be fully up to date on every aspect of primary health care, it's just far too wide a range.

 

In my case, the failing was made by the consultant I was referred to when still living in Cornwall.   @SteamyTea has already made reference to the pretty awful standards of health care down there, and sadly they've been like that for decades.  The failing was then compounded by five other GPs, as we moved around from place to place, who simply carried on prescribing various medications without questioning the original diagnosis.  The worst GP failing was the one before last, who ignored my evidence of apparently low blood pressure from home readings, when in reality my blood pressure was only a bit low because of the medication.

 

I'm about to change practice, so am hopeful that I can start off with a clean slate.  I have a feeling that I'm not flavour of the month with our current practice, with the exception of the new GP, as when she confirmed that I'd been misdiagnosed, and received medication for decades that didn't need, I wrote to the practice manager and because of the nature of the complaint she had to refer it to the NHS contracting team, who are currently investigating the whole practice.  Apparently mine hasn't been the only complaint, there have been others, although all I know is that, as the NHS complaints people wrote to me to confirm their investigation and mentioned that I was not the only complainant.

[TerryE]

My real point here is that Fluoxetine is an SSRI that might be an effective treatment for certain types of clinical depression, but there is evidence to support that CFS patients are in general suffering from clinical depression so IMO its use is entirely inappropriate.  As I said to my GP: I am fed-up with being bed-bound, but being fed-up is not the same as clinical depression, so no thank-you.  Most trials are funded by the drug majors who have vested interest in proving that long-term repeat prescription of some drug is an effective treatment.  The trials are badly constructed and often have shifting success criteria.  Those which reach negative conclusions are quietly shelved on cost grounds before being reported.   @JSHarris, I think that your being prescribed ARB is a good case in point. 

 

IMO, another case in point is the use of statins. I accept that they are effective in reducing the risk of heart disease if you have high blood pressure or other arterial problems, and especially if you don't exercise.  However, surely patients should be supported in trying to use dietary and life-style changes to address these risks first?  Or do we just give up and put everyone over 50 on the bloody things?

 

Edited May 18, 2018 by TerryE

[Onoff]

3 hours ago, newhome said:

 

Lol. Presume they kicked him into touch? 

 

 

 

Sadly yes. Too many old farts up in WK with nothing better to do that get behind a campaign against him. I was one of a very few who came out and wrote letters of support to the health authority and broadsheets etc. All to no avail but I reckon he has had the last laugh as is still practising locally whereas his old practice has failed dismally. I had some really nice messages from him and his wife thanking me. He wasn't pc and spoke his mind. I respected and really liked that. Put it this way we wouldn't likely have our kids without his help and advice.

[Jeremy Harris]

58 minutes ago, TerryE said:

IMO, another case in point is the use of statins. I accept that they are effective in reducing the risk of heart disease if you have high blood pressure or other arterial problems, and especially if you don't exercise.  However, surely patients should be supported in trying to use dietary and life-style changes to address these risks first?  Or do we just give up and put everyone over 50 on the bloody things?

 

All the Cochrane evidence on statins for the treatment of a wide range of conditions is here: http://www.cochrane.org/search/site/statins?f[0]=bundle%3Areview

 

It's fair to say that the evidence is not as powerful in some case as the popular press might make us believe, but that's also true of a fairly large number of medications.

 

I wholeheartedly agree with your cynicism with regard to the reporting of evidence from trials and studies.  I've probably reviewed about 40 or 50 sets of data from such trials or studies in recent months and the way the data has been manipulated in many of them is pretty shocking.

[TerryE]

The limitation of the Cochrane approach here is that it largely does meta analysis to aggregate the results of a related cluster of trials, and use statistical aggregation to draw out stronger conclusions than the individual studies can make.  The process does not deep dive into the individual studies to assess how well they implement best study practice, nor do they attempt to mine all of the abandoned studies that were coming up with the wrong answers.  So whilst Cochrane can remove silly outliers and represent the study consensus, they don't highlight systematic flaws or biases.  So in the case of use of statins for cardiovascular disease they correctly aggregated 18 RCTs comparing the use of statins against with usual care/placebo.  So yes,  treatment A which involves long-term expensive drugs is better than do nothing.  But treatment B which involves lifestyle changes on the part of the patient and potentially reduces the income of the drug companies has absolutely no chance of finding funding for trials, and so we can make no trail-based statements for treatment B vs do nothing or even treatment A vs treatment B.

 

I remember looking at a similar Cochrane review on ME/CFS and even went through the actual studies, and came away deeply uneasy and dissatisfied.  The average of a pile of shit is still a pile of shit. 

[Onoff]

When I was touching 20st and suffering debilitating headaches:

 

Practice Nurse: "Given your BP were going to put you on statins".

 

Me: "And I'd be on them for life?"

 

PN: "Yes!"

 

Me: "What's the alternative?"

 

PN: "Diet and excercise but you won't do that will you!"

 

 (Interesting that their go-to was statins straight away).

 

Me: "Watch me and btw you can keep your drugs!"

 

Just under 17st now for a few years and holding. They wanted me to 15 but I don't want to look too good and make SWMBO insecure!

 

 

 

 

 

 

 

 

[Jeremy Harris]

3 minutes ago, TerryE said:

The limitation of the Cochrane approach here is that it largely does meta analysis to aggregate the results of a related cluster of trials, and use statistical aggregation to draw out stronger conclusions than the individual studies can make.  The process does not deep dive into the individual studies to assess how well they implement best study practice, nor do they attempt to mine all of the abandoned studies that were coming up with the wrong answers.  So whilst Cochrane can remove silly outliers and represent the study consensus, they don't highlight systematic flaws or biases.  So in the case of use of statins for cardiovascular disease they correctly aggregated 18 RCTs comparing the use of statins against with usual care/placebo.  So yes,  treatment A which involves long-term expensive drugs is better than do nothing.  But treatment B which involves lifestyle changes on the part of the patient and potentially reduces the income of the drug companies has absolutely no chance of finding funding for trials, and so we can make no trail-based statements for treatment B vs do nothing or even treatment A vs treatment B.

 

I remember looking at a similar Cochrane review on ME/CFS and even went through the actual studies, and came away deeply uneasy and dissatisfied.  The average of a pile of shit is still a pile of shit. 

 

 

Cochrane does "deep dive" into as much data as can be obtained; reviewers spend a lot of voluntary free time doing this.  It may look, from the way the summaries are presented, as if each team has just done a metadata analysis, but that is not the case.  Every team has volunteer SMEs, as well as those who just collate data and try to correlate findings, and most teams have members who are experienced at peer reviewing academic papers, with the required degree of scientific scrutiny.  It's a volunteer organisation, so not perfect, but it does have the advantage of being run by people who have no vested interest in the outcomes of their work.

[TerryE]

1 minute ago, Onoff said:

Just under 17st now for a few years and holding.

 

Try sticking to a PK diet and we'll get you down to 15!

 

@JSHarris, at one stage, I did consider volunteering to be a Cochraine reviewer, so I do understand the process, but you have to work within the ToR of the published review and the data underpinning it.  In the case of medical trials, because of patient confidentiality, you rarely get to see anything other than sanitised data, and you only get access to the published content, as historically contemporaneous change control was rarely maintained in the trials process,  so it is very difficult to pick up practices such as in the PACE trials where they changed the study design during the study when it became clear from early results that the original design wasn't going to produce the desired outcome.

 

As I said the drug companies funded 18 statin trials, and no doubt Cochrane made sure that their conclusion that statins reduced fatal and non-fatal CVD compared to "do nothing".  No argument.

 

But taking Clive's case are statins@20st more effective than no statins@17st or even having someone on his case to get him to lose another stone or two and do a bit more exercise?  We can't say because this type of trial will never be funded.

 

At least statins are now available as generics and so the cost per patient is perhaps 10p /day.  But this isn't the case for more recent drugs.

[newhome]

1 hour ago, Onoff said:

He wasn't pc and spoke his mind. I respected and really liked that.

 

Yeah I can deal with that approach too but sadly too many snowflakes around these days who don’t want to hear straight talk. Clearly there is a time and a place however as you would hopefully not tell a terminally ill cancer patient that they will die a horrible death even when typically that’s what does happen, but telling someone who smokes that they might die a horrible death if they don’t give up, well that’s fair game really I think. 

 

[Trw144]

4 minutes ago, TerryE said:

At least statins are now available as generics and so the cost per patient is perhaps 10p /day.  But this isn't the case for more recent drugs.

 

No, and this is particularly so with modern precision medicines where the group of potential patients that can be treated are smaller and therefore the costs of the drug can be very high. There is currently a revolutionary new drug for cystic fibrosis but the drug manufacturer and NHS England can’t agree on its price (list is £100k per annum).

[Onoff]

8 minutes ago, TerryE said:

 

Try sticking to a PK diet and we'll get you down to 15!

 

OK I'm game! Point me at what foodstuffs I can eat. Nuts, berries, the odd bit of lean meat? I like nettles and squirrel...

[newhome]

28 minutes ago, Onoff said:

They wanted me to 15 but I don't want to look too good and make SWMBO insecure!

 

Ah bless you for being such a great husband!  Wasn’t this the same woman who doesn’t like heights hence your plan to work on the roof next? ?

 

As an aside, it’s 8.20 and I’m sitting on a beach in Scotland mid dog walk. Weather is amazing. Dogs are great exercise machines! Well for those who don’t have allergies anyway. 

[Jeremy Harris]

1 hour ago, TerryE said:

 

Try sticking to a PK diet and we'll get you down to 15!

 

@JSHarris, at one stage, I did consider volunteering to be a Cochraine reviewer, so I do understand the process, but you have to work within the ToR of the published review and the data underpinning it.  In the case of medical trials, because of patient confidentiality, you rarely get to see anything other than sanitised data, and you only get access to the published content, as historically contemporaneous change control was rarely maintained in the trials process,  so it is very difficult to pick up practices such as in the PACE trials where they changed the study design during the study when it became clear from early results that the original design wasn't going to produce the desired outcome.

 

As I said the drug companies funded 18 statin trials, and no doubt Cochrane made sure that their conclusion that statins reduced fatal and non-fatal CVD compared to "do nothing".  No argument.

 

But taking Clive's case are statins@20st more effective than no statins@17st or even having someone on his case to get him to lose another stone or two and do a bit more exercise?  We can't say because this type of trial will never be funded.

 

At least statins are now available as generics and so the cost per patient is perhaps 10p /day.  But this isn't the case for more recent drugs.

 

 

All experimental data of any value needs to be "double blind", so with medical trials there's never any issue of patient confidentiality, as patient ID is never in the data set anyway.

 

Yes, each team does, to some extent, define how it best conduct a review, but that is a consultative process, and is not imposed.  The main problem is getting reliable data, because the published data is often sanitised.  However, it's usually pretty obvious when comparing the data from several trials or studies where data has been sanitised, and there is a gradual shift towards allowing reviewers better access to raw data.  In part this has been driven by the growing trust placed in Cochrane evidence, but I think the main reason for the shift has been the realisation by drug companies that they were being shown up as only publishing sanitised results.

[Ferdinand]

10 hours ago, newhome said:

 

Ah bless you for being such a great husband!  Wasn’t this the same woman who doesn’t like heights hence your plan to work on the roof next? ?

 

As an aside, it’s 8.20 and I’m sitting on a beach in Scotland mid dog walk. Weather is amazing. Dogs are great exercise machines! Well for those who don’t have allergies anyway. 

 

Buildhub prescribes a husky or a sheepdog ?.

 

Personally I would say utility cycling.

 

F

 

[ToughButterCup]

12 hours ago, TerryE said:

[...] Or do we just give up and put everyone over 50 on the bloody things?

 

Yes, because it's easy.

[newhome]

36 minutes ago, Ferdinand said:

 

Buildhub prescribes a husky or a sheepdog ?.

 

Personally I would say utility cycling.

 

 

No huskys. You can’t let the damn things off lead or they disappear. 

 

Cycling doesn’t work too well on the beach so I’ll stick to walking dogs