So Where Are We up to with Alcohol and Health?

First, let me come clean – I am a moderate drinker. No doubt about it. Five nights a week on a mean of two glasses, and two nights on a mean of three glasses. These are average sized glasses, so let’s say 24 units (1.5 x 16) per week. I love wine and seek good news…

The story so far:

  1. There is a ‘J-shaped’ curve of the association between alcohol and many diseases.[1]
    093 - Alcohol j curve
    * Cancer does not follow this pattern. Cancers of mouth, throat and gullet are almost certainly increased, and probably breast too.[2]
  2. But Mendelian randomisation (inheriting genes predisposing to alcohol consumption) does not show a J-shaped curve – risk rises incrementally.[3]
  3. Longitudinal studies show that, on one dimension of cognition, decline is faster in linear relationship to alcohol dose, and this finding ‘triangulates’ with a drop in right-sided hippocampal volume (detected by MRI) in relation to alcohol intake.[4]

Conclusion: the J-shaped curve is an artefact of selection bias.

So what’s new? First, a meta-analysis of longitudinal studies [5] shows a substantial protective effect against dementia for low to moderate alcohol intake (RR 0.63, 0.53-0.75) and also in Alzheimer’s disease (RR 0.57, 0.44-0.74). Second, there some evidence from these studies that chronic drinking is protective of cognitive decline, while episodic drinking is harmful at the same total intake. Third, a new longitudinal study suggests that chronic (i.e. non-binge) drinking is indeed protective against cognitive impairment in older people.[6]

This new study (the Rancho Bernardo study) is based on a cohort of 6,339 middle-class residents of a suburb in San Diego. Of the surviving residents, 2,479 attended a research clinic in 1985 where detailed alcohol histories were elicited. The participants were followed up every four years with cognitive tests. Co-variates were collected and added sequentially to a logistic regression model, starting with those (e.g. sex and age) least likely to be on the causal pathway linking alcohol to outcome. The APOE genotype was examined as an interaction term. Potential confounding effects of diet were also examined. Various sensitivity analyses were conducted. Drinking up to 3 units per day after age 65, and 4 units per day at a younger age significantly increased the chance of healthy survival, with an odds ratio exceeding 2. The J curve is there in the data, with the probability of healthy longevity increasing through no, low, moderate and even heavy drinking, only to decline again when drinking was ‘excessive’ (meaning over 4 drinks per day aged under 65 and over 3 per day for men over 65, and 3 or 2 drinks per day in younger or older women. And, yes, more frequent drinking is better than episodic drinking at a given intake – ORs of Cognitively Health Longevity increased three-fold with daily drinking vs. not drinking at all, but only two-fold if drinking was ‘infrequent’. Conclusions were robust to various sensitivity analyses.

What is the truth? No person knoweth it! But the idea that regular, moderate drinking offers some protective effects to trade-off against cancer risk has empirical support. I wonder if there are different genes predisposing to binge vs. steady drinking? I hypothesise that the genes are associated with poor impulse control leading to binge drinking. I hope that this hypothesis will now be put to an empirical test. Another question, of course, concerns the type of drink. The middle-class people in the Rancho Bernardo study may have favoured wine over other drinks – I hope so!

— Richard Lilford, CLAHRC WM Director

References:

  1. Di Castelnuovo A, Costanzo  S, Bagnardi  V, Donati  MB, Iacoviello  L, de Gaetano    Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies.  Arch Intern Med. 2006; 166(22): 2437-45.
  2. Lilford RJ. Oh Dear – Evidence Against Alcohol Accumulates. NIHR CLAHRC West Midlands News Blog. 7 December, 2017.
  3. Holmes MV, Dale CE, Zuccolo L, et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ. 2014; 349: g4164.
  4. Lilford RJ. Alcohol and its Effects. NIHR CLAHRC West Midlands News Blog. 18 August, 2017.
  5. Peters R, Peters J, Warner J, Beckett N, Bulpitt C. Alcohol, dementia and cognitive decline in the elderly: a systematic review. Age Ageing. 2008; 37(5): 505-12.
  6. Richard EL, Kritz-Silverstein D, Laughlin GA, Fung TT, Barrett-Connor E, McEvoy LK. Alcohol Intake and Cognitively Healthy Longevity in Community-Dwelling Adults: The Rancho Bernardo Study. J Alzheimer’s Dis. 2017; 59: 803-14.
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A Calming Scent

In a previous News Blog we looked at a study investigating associations between body odour and attractiveness to strangers.[1] But what about the smell of someone we already love? A recent study randomly assigned 96 women to smell the scent of either their partner, a stranger, or a neutral unworn shirt, before exposing them to stress through a standardised mock job interview and an unanticipated mental arithmetic task.[2] The results found that women exposed to their partner’s scent perceived lower levels of stress both before and after the stressor task (though not during). Further women exposed to a stranger’s scent had higher levels of cortisol throughout the study, which is released in response to stress.

Perhaps providing worn clothing from a loved one could be a useful coping strategy for people who have been separated, for example, in elderly patients in care homes.

— Peter Chilton, Research Fellow

References:

  1. Lilford RJ. The Scent of a Woman – Not as Important as Once Thought. NIHR CLAHRC West Midlands News Blog. 24 November 2017.
  2. Hofer MK, Collins HK, Whillans AV, Chen FS. Olfactory Cues From Romantic Partners and Strangers Influence Women’s Responses to Stress. J Person Soc Psychol. 2018; 114(1): 1-9.

New Framework to Guide the Evaluation of Technology-Supported Services

Heath and care providers are looking to digital technologies to enhance care provision and fill gaps where resource is limited. There is a very large body of research on their use, brought together in reviews, which among many others, include, establishing effectiveness in behaviour change for smoking cessation and encouraging adherence to ART,[1] demonstrating improved utilisation of maternal and child health services in low- and middle-income countries,[2] and delineating the potential for improvement in access to health care for marginalised groups.[3] Frameworks to guide health and care providers when considering the use of digital technologies are also numerous. Mehl and Labrique’s framework aims to help a low- or middle-income country consider how they can use digital mobile health innovation to help succeed in the ambition to achieving universal health coverage.[4] The framework tells us what is somewhat obvious, but by bringing it together it provides a powerful tool for thinking, planning, and countering pressure from interest groups with other ambitions. The ARCHIE framework developed by Greenhalgh, et al.[5] is a similar tool but for people with the ambition of using telehealth and telecare to improve the daily lives of individuals living with health problems. It sets out principles for people developing, implementing, and supporting telehealth and telecare systems so they are more likely to work. It is a framework that, again, can be used to counter pressure from interest groups more interested in the product than the impact of the product on people and the health and care service. Greenhalgh and team have now produced a further framework that is very timely as it provides us with a tool for thinking through the potential for scale-up and sustainability of health and care technologies.[6]

Greenhalgh, et al. reviewed 28 previously published technology implementation frameworks in order to develop their framework, and use their own studies of digital assistive technologies to test the framework. Like the other frameworks this provides health and care providers with a powerful tool for thinking, planning and resisting. The Domains in the Framework include, among others, the health condition, the technology, the adopter system (staff, patients, carers), the organisation, and the Domain of time – how the technology embeds and is adapted over time. For each Domain in the Framework the question is asked whether it is simple, complicated or complex in relation to scale-up and sustainability of the technology. For example, the nature of the condition: is it well understood and predictable (simple), or poorly understood and unpredictable (complex)? Asking this question for each Domain allows us to avoid the pitfall of thinking something is simple when it is in reality complex. For example, there may be a lot of variability in the health condition between patients, but the technology may have been designed with a simplified textbook notion of the condition in mind. I suggest that even where clinicians are involved in the design of interventions, it is easy for them to forget how often they see patients that are not like the textbook, as they, almost without thinking, deploy their skills to adapt treatment and management to the particular patient. Greenhalgh, et al. cautiously conclude that “it is complexity in multiple domains that poses the greatest challenge to scale-up, spread and sustainability”. They provide examples where unrecognised complexity stops in its tracks the use of a technology.

— Frances Griffiths, Professor of Medicine in Society

References:

  1. Free C, Phillips G, Galli L. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med. 2013;10:e1001362.
  2. Sondaal SFV, Browne JL, Amoakoh-Coleman M, Borgstein A, Miltenburg AS, Verwijs M, et al. Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review. PLoS One. 2016;11(5):e0154664.
  3. Huxley CJ, Atherton H, Watkins JA, Griffiths F. Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice. Br J Gen Pract. 2015;65(641):e813-21.
  4. Mehl G, Labrique A. Prioritising integrated mHealth strategies for universal health coverage. Science. 2014;345:1284.
  5. Greenhalgh T, Procter R, Wherton J, Sugarhood P, Hinder S, Rouncefield M. What is quality in assisted living technology? The ARCHIE framework for effective telehealth and telecare services. BMC Medicine. 2015;13(1):91.
  6. Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A’Court C, et al. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res. 2017;19(11):e367.

High ‘Tight’ is Tight Enough for Control of Type 2 Diabetes

Two recent papers touch on the important subject of drug treatment of type 2 diabetes.[1] [2] The first paper deals with the risks of ‘tight’ control, and the second examines the effect of ‘tight control’ on the microvascular complications of diabetes. So what is meant by ‘control’ vs. ‘tight control’. ‘Control’ brings HbA1c levels into the range 7-8%, while ‘tight control’ brings it under 7%. Both papers cast doubt on the value of ‘tight control’ vs. just ‘control’ achieved by pharmacological means. The first paper points out that ‘tight’ pharmacological control is associated with an increased risk of sudden death when compared to ‘control’.[1] This is thought to result from an increased incidence and severity of severe hypoglycaemic episodes when insulin doses are ramped up to achieve ‘tight’ control. The second paper, based on a review of RCT evidence,[2] finds that microvascular disease (causing blindness, renal failure, leg ulcers) is not measurably reduced by ‘tight control’ vs. ‘control’. So there we have it – ‘tight’ pharmacological control introduces the hazard of sudden death for no countervailing benefit in long-term outcomes. To put this another way, going from ‘control’ to ‘tight control’ increases the risk of sudden death for little, if any, compensatory advantage.

If there are limits to what can be achieved by ramping up pharmacological treatment, then what about dieting to the point that diabetes goes into remission? The evidence suggest that three-quarters of people with type 2 diabetes will achieve remission if they lose at least 15kg of weight. Bariatric surgery is highly effective in resulting in sustained weight loss.[3] Up to 10% of people can achieve a 15kg drop in weight by dieting alone, but about one-third of them revert each year. Nevertheless, it is worth trying hard to achieve weight loss because societal and personal gains are immense. And we have argued before for an inexpensive model to increase access to bariatric surgery.[4] [5]

Thank you to Ewan Hamnett for drawing my attention to this paper.

— Richard Lilford, CLAHRC WM Director

References:

  1. McCombie L, Leslie W, Taylor R, Kennon B, Sattar N, Lean MEJ. Beating type 2 diabetes into remission. BMJ. 2017; 358: j4030.
  2. Rodriguez-Gutierrez R & Montori VM. Glycemic Control for Patients with Type 2 Diabetes: Our Evolving Faith in the Face of Evidence. Circ Cardiovasc Qual Outcomes. 2016; 9(5): 504-12.
  3. Schaeur PR, Bhatt DL, Kirwan JP, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 5-Year OutcomesNew Engl J Med. 2017; 376: 641-51.
  4. Lilford RJ. Bariatric Surgery – Improve Five-Year Outcomes. NIHR CLAHRC West Midlands News Blog. 23 June, 2017.
  5. Lilford RJ. Is It Safe for One Surgeon to Oversee Two Operations Concurrently? NIHR CLAHRC West Midlands News Blog. 27 October, 2017.

Patient’s experience of hospital care at weekends

The “weekend effect”, whereby patients admitted to hospitals during weekends appear to be associated with higher mortality compared with patients who are admitted during weekdays, has received substantial attention from the health service community and the general public alike.[1] Evidence of the weekend effect was used to support the introduction of ‘7-day Service’ policy and associated changes to junior doctor’s contracting arrangement by the NHS,[2-4] which have further propelled debates surrounding the nature and causes of the weekend effect.

Members of the CLAHRC West Midlands are closely involved in the HiSLAC project,[5] which is an NIHR HS&DR Programme funded project led by Professor Julian Bion (University of Birmingham) to evaluate the impact of introducing 7-day consultant-led acute medical services. We are undertaking a systematic review of the weekend effect as part of the project,[6] and one of our challenges is to catch up with the rapidly growing literature fuelled by the public and political attention. Despite that hundreds of papers on this topic have been published, there has been a distinct gap in the academic literature – most of the published papers focus on comparing hospital mortality rates between weekends and weekdays, but virtually no study have compared quantitatively the experience and satisfaction of patients between weekends and weekdays. This was the case until we found a study recently published by Chris Graham of the Picker Institute, who has unique access to data not in the public domain, i.e. the dates of admission to hospital given by the respondents.[7]

This interesting study examined data from two nationwide surveys of acute hospitals in 2014 in England: the A&E department patient survey (with 39,320 respondents representing a 34% response rate) and the adult inpatient survey (with 59,083 respondents representing a 47% response rate). Patients admitted at weekends were less likely to respond compared to those admitted during weekdays, but this was accounted for by patient and admission characteristics (e.g. age groups). Contrary to the inference that would be made on care quality based on hospital mortality rates, respondents attending hospital A&E department during weekends actually reported better experiences with regard to ‘doctors and nurses’ and ‘care and treatment’ compared with those attending during weekdays. Patients who were admitted to hospital through A&E during weekends also rated information given to them in the A&E more favourably. No other significant differences in the reported patient experiences were observed between weekend and weekday A&E visits and hospital admissions. [7]

As always, some cautions are needed when interpreting these intriguing findings. First, as the author acknowledged, patients who died following the A&E visits/admissions were excluded from the surveys, and therefore their experiences were not captured. Second, although potential differences in case mix including age, sex, urgency of admission (elective or not), requirement of a proxy for completing the surveys and presence of long-term conditions were taken into account in the aforementioned findings, the statistical adjustment did not include important factors such as main diagnosis and disease severity which could confound patient experience. Readers may doubt whether these factors could overturn the finding. In that case the mechanisms by which weekend admission may lead to improved satisfaction Is unclear. It is possible that patients have different expectations in terms of hospital care that they receive by day of the week and consequently may rate the same level of care differently. The findings from this study are certainly a very valuable addition to the growing literature that starts to unfold the complexity behind the weekend effect, and are a further testament that measuring care quality based on mortality rates alone is unreliable and certainly insufficient, a point that has long been highlighted by the Director of the CLAHRC West Midlands and other colleagues.[8] [9] Our HiSLAC project continues to collect and examine qualitative,[10] quantitative,[5] [6] and economic [11] evidence related to this topic, so watch the space!

— Yen-Fu Chen, Principal Research Fellow

References:

  1. Lilford RJ, Chen YF. The ubiquitous weekend effect: moving past proving it exists to clarifying what causes it. BMJ Qual Saf 2015;24(8):480-2.
  2. House of Commons. Oral answers to questions: Health. 2015. House of Commons, London.
  3. McKee M. The weekend effect: now you see it, now you don’t. BMJ 2016;353:i2750.
  4. NHS England. Seven day hospital services: the clinical case. 2017.
  5. Bion J, Aldridge CP, Girling A, et al. Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays. BMJ Open 2017;7:e018747.
  6. Chen YF, Boyal A, Sutton E, et al. The magnitude and mechanisms of the weekend effect in hospital admissions: A protocol for a mixed methods review incorporating a systematic review and framework synthesis. Systems Review 2016;5:84.
  7. Graham C. People’s experiences of hospital care on the weekend: secondary analysis of data from two national patient surveys. BMJ Qual Saf 2017;29:29.
  8. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Qual Saf 2012;21(12):1052-56.
  9. Lilford R, Pronovost P. Using hospital mortality rates to judge hospital performance: a bad idea that just won’t go away. BMJ 2010;340:c2016.
  10. Tarrant C, Sutton E, Angell E, Aldridge CP, Boyal A, Bion J. The ‘weekend effect’ in acute medicine: a protocol for a team-based ethnography of weekend care for medical patients in acute hospital settings. BMJ Open 2017;7: e016755.
  11. Watson SI, Chen YF, Bion JF, Aldridge CP, Girling A, Lilford RJ. Protocol for the health economic evaluation of increasing the weekend specialist to patient ratio in hospitals in England. BMJ Open 2018:In press.

Worms – Not Just Useful in the Garden

It is known that worms are ‘old infections’ and that old infections tend to manipulate their host’s immune system to their advantage – they use the immune system to hide from attack by the immune system. It is not altogether surprising, then, that worms can affect non-infective diseases. Previous research has shown infections protecting people from atopy.[1] Now it turns out that worm infestation might also offer protection against inflammatory bowel disease.[2] One possibility is that they do this by altering intestinal flora and reducing the load of bacteria that promote infection.[2] [3] Certain people who are predisposed to inflammatory bowel disease might gain protection from worm infestation.

— Richard Lilford, CLAHRC WM Director

References:

  1. Smits HH, Everts B, Hartgers FC, Yazdanbakhsh M. Chronic Helminth Infections Protect Against Allergic Diseases by Active Regulatory Processes. Curr Allergy Asthma Rep. 2010; 10(1): 3-12.
  2. Ramanan D, Bowcutt R, Lee SC, et al. Helminth infection promotes colonization resistance via type 2 immunity. Science. 2016; 352(6285): 608-12.
  3. Leslie M. Parasitic worms may prevent Crohn’s disease by altering bacterial balance. Science. 24 April 2016.

Risks of Children Using Technology Before Bed

We live in an increasingly technologically connected society, which even extends to children – for example, 74% of children (9-16 years old) in the UK use a mobile phone, with most receiving their first phone at the age of 10 years old;[1] while around half have a television in their bedroom at age 7.[2] For many it can be difficult to switch off at the end of the day – the allure of one more video, or another scan of social media can be strong. As such, many children use technology at bedtime, which may impact on their sleep as the light emitted by these devices has a higher concentration of ‘blue light’, which affects the levels of melatonin, a sleep-inducing hormone.[3] Previous research has shown the importance of sleep on children’s health and behaviour, and so Fuller and colleagues conducted a study looking at use of technology at bedtime and its effects on various health outcomes.[4] They surveyed 207 parents of 8-17 year olds and found that children who watched television at bedtime were significantly more likely to be overweight or obese than those who did not (odds ratio 2.4, 95% CI 1.35-4.18). Similar results were found for children who used a phone at bedtime (OR=2.3, 95% CI 1.31-4.05). There were no significant differences seen with computer or video game use. The authors also looked at sleeping behaviour and found a significant relationship between average hours of sleep and bedtime use of television (P=0.025), phone (P<0.001), computer (P<0.001), and video games (P=0.02). Further analysis showed that children who used various technologies were also more likely to be tired in the morning, less likely to eat breakfast, and more likely to text during the middle of the night. The authors recommend setting up ‘tech-free’ zones and making sure that devices are charged outside of the child’s bedroom.

Of course, this study only shows an association – it may be that some children have difficulty getting to sleep and so turn to technology in order to help them drift off. Meanwhile, the study is subject to reporting bias from the self-reported surveys of the parents, and so further studies are needed.

— Peter Chilton, Research Fellow

References:

  1. GSMA report. https://www.gsma.com/publicpolicy/wp-content/uploads/2012/03/GSMA_Childrens_use_of_mobile_phones_2014.pdf. 2014.
  2. Heilmann A, Rouxel P, Fitzsimons E, Kelly Y, Watt RG. Longitudinal associations between television in the bedroom and body fatness in a UK cohort study. Int J Obes. 2017; 41: 1503-9.
  3. Fuller C, Lehman E, Hicks S, Novick MB. Bedtime Use of Technology and Associated Sleep Problems in Children. Glob Pediatr Health. 2017.
  4. Schmerler J. Q&A: Why Is Blue Light before Bedtime Bad for Sleep? Scientific American. 01 September 2015.

Traditional Healers and Mental Health

The case for traditional healers in mental health

There are two arguments for traditional healer involvement in mental health provision; one pragmatic and one theoretical. The pragmatic argument turns on the huge shortfall in human resources to deal with mental health problems in low- and middle-income countries (LMICs).[1] Traditional healers could make up for this shortage in human resources in the formal sector. A theoretical argument for the role of traditional healers turns on cultural factors. The argument here is that traditional healers are ideally placed to intervene in conditions with social origins, or when symptoms are coloured by cultural assumptions. Traditional healers, one might suppose, can tap into the beliefs and expectation of local people to reach parts of the mind that are simply inaccessible under a ‘medical model’. According to this argument modern medicine is the appropriate vehicle for the diagnosis and management for the conditions that are mainly of the body. It would be unwise, for example, to rely on traditional healers for the treatment of an acutely febrile child, or for provision of contraceptive advice. However, the traditional healer might be the appropriate first port of call for people with conditions of the mind.

The case against traditional healers in mental health

An argument against the above position is that the most serious types of mental health condition, psychotic illnesses, require modern pharmacotherapy, at least to stabilise patients. While all psychiatric conditions are of both brain and mind, psychotic conditions can be closer in form to those of standard medical diseases and the effects of properly targeted chemotherapy can be dramatic. There are many well documented cases where access to appropriate pharmacological therapy was denied or cruelly delayed while patients were treated unsuccessfully by traditional healers. From this perspective one should no more consult a traditional healer for a mental illness than for suspected malaria.

Reconciling the case for and against: a topic for investigation and research

On the one hand, traditional healers can offer culturally sensitive treatment for non-psychotic conditions, while on the other hand, severe mental illness requires medical services. It could be argued that traditional and modern medical services should be integrated so that traditional healers could treat the majority of patients, i.e. those with non-psychotic diseases, while allopathic clinicians treat the more severe cases. Moreover, different people have different preferences, and individuals may wish to receive care from both types of providers, even for the same illness. These would seem to be further arguments to integrate traditional and allopathic services within the same system and, indeed, in an integrated reimbursement system. Before implementing such a system it would surely be sensible to evaluate the effectiveness of traditional healers in the treatment of various psychiatric conditions and to ensure that, with the appropriate education, they would be able to refer cases that need medical treatment.

Philosophical problems in collaboration between traditional healing and modern medicine

The CLAHRC WM Director is keen to explore the relative effectiveness of traditional and allopathic treatments for non-psychotic mental illness but he is concerned that there may be irreconcilable philosophical differences in the traditional versus allopathic approach. This concern arises from different ontologies that underpin the different kinds of service. That is to say these traditions have different views on what counts as truth. Modern medical practice is very much a product of what might be called ‘enlightenment thinking’; practice built on an understanding of biological mechanisms / scientific explanations.[2] Such a world view is a far cry from the assumptions that underpin traditional healing, and which are guided by a set of traditional beliefs, often of a religious nature. So the question is whether it is possible to truly integrate systems with such different sets of underpinning assumptions? This is partly an empirical question – different systems could be examined to understand how well they can work together. The CLAHRC WM Director understands that moves are afoot to integrate allopathic medicine with traditional Chinese medicine in China, and in Ayurvedic medicine in India. It would be interesting to make independent studies of these systems. But in the meantime I would suggest a thought experiment. Let us imagine a proposed trial of rose-hip water vs. anti-depressant medication taking place in an integrated hospital. The allopathic practitioners present this as a placebo-controlled trial, while the traditional healers present this as a trail of two effective alternatives – the underlying belief systems determine how the treatments are presented. The CLAHRC WM Director suspects that it is very difficult to really integrate two systems based on very different philosophical premises. It is one thing to make irenic statements about mutual respect and so on, but another to supress tensions that seem likely to arise from fundamentally irreconcilable philosophical assumptions.

Living with contradictions

The question of integrating these different systems of thought is, perhaps, unresolvable. The systems have existed side by side for a hundred years or more. In high-income countries there is a thriving industry in complementary therapies and the list of alternative methods is almost too long to recite. Likewise traditional medicine and modern medicine have existed side by side quite happily in Africa, South Asia and China for many years. The populations in all these countries seem, on the whole, pretty savvy at working out which method is more appropriate for them in which condition. I have never heard of anyone going to a homeopath for their family planning needs. But systems co-existing in society is one thing, integrating them in common administrative and reimbursement systems is another. Every now and then there is an attempt to unite religion and science around a common purpose – the Lancet commission is currently involved in such a process.[3] [4] However, it may be the case that like religion and science; traditional and allopathic medicine can live happily side by side within the same community and within the same individual. Whether and how they can really be brought together in a structural / organisational sense, for example in the same institution or within the same reimbursement system, is a matter for analysis and exploration. One thing I am sure of is that policy should not be made as though this were a technical issue and without considering the very different world views that lie behind each type of provision. Maybe the best that can be accomplished is for the systems to become more aware of each other and cross-refer when necessary, but to continue to make their own independent contributions?

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Rathod S, Pinninti N, Irfan M, Gorczynski P, Rathod P, Gega L, Naeem F. Mental Health Service Provision in Low- and Middle-Income Countries. Health Serv Insights. 2017; 10:
  2. Spray EC. Health and Medicine in the Enlightenment. Jackon M (ed). The Oxford Handbook of the History of Medicine. 2011.
  3. Horton R. When The Lancet went to the Vatican. Lancet. 2017; 389: 1500.
  4. Lee N, Remuzzi G, Horton R. The Vatican-Mario Negri-Lancet Commission on the value of life. Lancet. 2017; 390: 1573.

Oh Dear – Evidence Against Alcohol Accumulates

Yes, more research [1] [2] on alcohol – increases in cancers of mouth, throat and oesophagus. Not good places to have cancer. Direct contact of C2-H5-OH with the membrane is the likely causal mechanism. So here is an hypothesis – the more dilute a given amount of alcohol, the better. So I think beer > wine > spirits, ceteris paribus. I guess this has been tested? But next week I may have some more reassuring news for us oenophiles.

— Richard Lilford, CLAHRC WM Director

References:

  1. LoConte NK, Brewster AM, Kaur JS, Merrill JK, Alberg AJ. Alcohol and Cancer: A Statement of the American Society of Clinical Oncology. J Clin Oncol. 2017; 35: 1-11.
  2. The Lancet. Alcohol and cancer. Lancet. 2017. 390: 2215.

Intensive Care Harmful in Elderly Patients

An intervention to promote use of intensive care in elderly patients (over age 75) was evaluated in a cluster RCT of 20 French hospitals.[1] The intervention worked in the narrow sense that it did increase the rate of admission to the intensive care unit (ICU) (by nearly 70%). But did this result in improved survival? Not at all – in fact there was a statistically significant increase in death rates in the hospitals randomised to have lower thresholds for ICU care; both in hospital (18% increase) and at 6 months (16% increase). So a conservative policy dominates – it is both less expensive and more effective in old people. But this paper should make one think – how effective is ICU for other groups of patients? Apart from looking after people who need a breathing machine, is ICU really an effective treatment at all? It is highly invasive and intrusive. I am not a therapeutic nihilist, but one does have to wonder. Perhaps we should design a less intensive form of intensive care? Such an approach could be evaluated in RCTs before advocating global use of the current standard ICU model in high-income countries. Let me annoy my colleagues by proposing a hypothesis. ICU types think that it is the monitoring and fiddling with vital signs that saves lives. I think the main effect is better diagnosis – because patients are scrutinised carefully by highly trained people, conditions are spotted that would otherwise be missed. Just a thought!

I would like to thank News Blog reader Gus Hamilton for drawing my attention to this article.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Guidet B, Leblanc G, Simon T, et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial. JAMA. 2017; 318(15): 1450-9.