Medical students 1 Grumpy old GP 0

Lovely rant in the Daily Mail about how these new fangled young doctors 'can't diagnose for toffee'. It contains this gem about tactile vocal fremitus:

If they had pneumonia, and therefore fluid on the lungs, the voice would sound high-pitched, and the vibrations would be reduced. Maybe not infallible, but pretty slick, right

Oh dear, we'll leave aside that vocal resonance is a better test, and that you wouldn't test for vocal fremitus if the rest of examination was normal anyway, no, the point here is that the vibrations would be increased in pneumonia!* I'd expect my medical students to know this, let alone a GP. What a clown.



* Don't give me any obfuscatory crap about a parapneumonic effusion - if that's what he meant that's what he'd have said.

Don't trust the media

Words fail me:
ITV documentary can’t tell the difference between gaming and reality; mistakes Arma 2 for secret IRA film

Undercover Care: The Abuse Exposed

Watch this on the BBC: "Undercover Care: The Abuse Exposed". And then reflect on the failings of the Care Quality Commission in this case* and whether they could detect or act to investigate any similar case in the future**:

"A specialist residential hospital in Bristol is being investigated by police after secret filming by BBC Panorama found a pattern of serious abuse.

"During five weeks spent filming undercover, Panorama's reporter captured footage of some of the hospital's most vulnerable patients being repeatedly pinned down, slapped, dragged into showers while fully clothed, taunted and teased.

"The programme decided to secret film after being approached by a former senior nurse at the hospital who was deeply concerned about the behaviour of some of the support workers caring for patients.

"Mr Bryan reported his concerns to both management at Winterbourne View and to the government regulator, the Care Quality Commission (CQC) but his complaint was not taken up.
Ian Biggs, regional direction of the CQC for the southwest, said an opportunity to prevent abuse was missed when Mr Bryan's complaints were not investigated."

* Headed by the former chief executive of West Midlands strategic health authority (SHA) who presided over the Mid Staffordshire scandal lest we forget, so she has relevant expertise in this area!

** Still, at least the unit concerned probably had policies for dealing with dog mess, so it can't have been all bad as far as the CQC are concerned.

Scaring women - easy, profitable, and fun

According to the Telegraph:

"Researchers say there might be no safe limit for the amount of alcohol a pregnant woman can drink without endangering her unborn child

"However, now researchers in Ireland have found evidence that women who drink up to five units a week, equivalent to two 175ml glasses of red wine, could be putting their children at risk of fetal alcohol syndrome.

"The study found three cases of fetal alcohol syndrome "one each in the low, moderate and high consumption groups". The fact there was one in the low alcohol consumption group led the researchers to question the theory that light drinking had no effect on a baby's health."

Well this is the paper, in BMC Pregnancy and Childbirth, the abstract sums it up pretty well:

"A cohort study of 61,241 women who booked for antenatal care and delivered in a large urban maternity hospital between 2000 and 2007. Self-reported alcohol consumption at the booking visit was categorised as low (0-5 units per week), moderate (6-20 units per week) and high (> 20 units per week).

"Of the 81% of women who reported alcohol consumption during the peri-conceptional period, 71% reported low intake, 9.9% moderate intake and 0.2% high intake.

"High consumption was associated with very preterm birth (< 32 weeks gestation) even after controlling for socio-demographic factors adjusted OR 3.15 (95% CI 1.26-7.88). Only three cases of Fetal Alcohol Syndrome were recorded (0.05 per 1000 total births), one each in the low, moderate and high consumption groups."

If we assume all births were single babies (since most will be, and the twins and higher number births will not affect the numbers much) that's rates of foetal alcohol syndrome (FAS) of .0023%, .016%, and .82% in the low, moderate, and high risk groups respectively. That gives a relative risk of FAS in the high alcohol consumption group of over 300x the low consumption group.

Interestingly the overall FAS rate in the study is 1/10th of the usual estimated rate, probably because this was only those infants detected in the baby check in hospital. So, in conclusion, there were only 3 cases of FAS in this study which is both very low, and also too small to really draw too many conclusions. Any claim about low alcohol consumption causing FAS is basically a case report of one child that occurred with a rate of .0023%.

Importantly, we have to remember that FAS is believed to be due to heavy drinking throughout pregnancy, and the study did not record this, only alcohol consumption early in pregnancy. If the mother of the FAS child in the low alcohol group was under-reporting her alcohol consumption or went on to drink more heavily throughout pregnancy we have no evidence for a risk of FAS in low alcohol consumption in this study.

So did the authors really cause such an unnecessary scare by claiming that low alcohol consumption causes FAS as the Telegraph reports? Well here they are in the paper:

"This suggests that the mothers of the first two infants [the low and moderate alcohol consumption cases of FAS] may have under-reported their alcohol intake at the time of booking as FAS is unlikely to occur at lower levels of alcohol intake" [my emphasis]

Apparently not. So just another PR/journalist manufactured scare because worrying women about pregnancy, childbirth, and child rearing is easy, profitable, and fun.

A campaign for social science

Via Church of Rationality I came across this little proposal:

"...I would set up a campaign for social science.
This would be a little different from More or Less or Bad Science, great as they are. Very often, they deal with the abuse of statistics. I’m thinking not just of this, but of fact-free hand-waving. What my campaign would do is insist upon more scientific standards of discussion of social affairs. 

"Now, I don’t know how such a campaign would change politics. I suspect that, very often, it would reveal just how much we don’t know. But it would revolutionize the media. TV and radio would have to drop all those blowhards who just exchange anecdote and hypothesis; in proper science, no-one give a damn abot anyone's opinion - it's the evidence that matters. And it might even reverse the inequality of pay and status between columnists and reporters. "

Placebos in medicine

Good short response on Comment is Free by Oxford Psychiatry Professor Tom Burns on the use of placebos in medicine and how the media exaggerates the beneficial effects*:

When researchers write, for example, that 20% of the placebo group recovered in a trial and 60% of the active treatment group did, they are not saying that placebos "have the same effect" in a third as many of the patients. They mean that (for the patients with this condition) 20% will recover in the natural course of events, but with the added treatment 60% will recover. It is this added 40% that matters. The placebo has had no effect on recovery.

This lead me to a good article he wrote in response to Richard Bentall's tedious criticisms of psychiatry:

Richard Bentall is right: psychological and social psychiatry research has been a Cinderella to biological and genetic explanations...He is also spot on about the exaggeration and hype of many of their "breakthroughs".

However, much of his article is so one-sided that those messages risk being lost.

 

* The seminal Cochrane review on this topic by Hróbjartsson & Gøtzsche found:

We found an effect on pain...nausea...asthma...and phobia...

There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.

Schizophrenia in the Guardian

A rather nice little piece on a man with schizophrenia and his father who have written a book about the experience:

"To Patrick Cockburn, it's an illness that has eaten away at his oldest child. To Henry, it has been a revelation. Father and son tell Amanda Mitchison how schizophrenia has changed them both"

Stephen Hawking rules modern art is rubbish after all

I love the idea that the world was basically waiting with baited breath for Stephen Hawking to make a ruling on the existence of God:

There is no place for God in theories on the creation of the Universe, Professor Stephen Hawking has said.

He had previously argued belief in a creator was not incompatible with science but in a new book, he concludes the Big Bang was an inevitable consequence of the laws of physics.

The Daily Mash:

"And - though it probably goes without saying - if the creation did not involve chocolate or monkey balloons, then who made your so-called 'physics'? Thrust and parry!"

Professor Hawking had previously argued that a 'grand unified theory of everything' could offer a glimpse inside the mind of chocolate but now accepts that such a discovery would finally make chocolate irrelevant, except for maybe Aeros and Wispas.

Panorama and migration

Vaguely watching this dull Panorama, sensationalised and tabloid as all Parorama documentaries have become, about population pressures in the UK, concentrating, it will not surprise you, on blaming it all on immigrants: "there's a widespread belief that migrants get preferential access to housing...[insert glaring lack of any attempt to actually answer whether this is the case or not]"

But I was struck by the figure of immigration benefiting the UK by "only 60p per person per week" (contrast this with Migration Watch's previous figure of 4p) apparently sourced from this Lords report (although I can't find that specific figure), and contrasted with the 'misleading' government use of the benefit to GDP of immigration.:

The total size of an economy is not an index of prosperity. The focus of analysis should rather be on the effects of immigration on income per head of the resident population.

The report makes an interesting point about how while in the short term migrants fill vacancies in he economy but in the long term the economy proportionately expands (increasing vacancies again). But in emphasising the raw monetary figure of per capita increase in GDP I think it is equally if not more misleading than the government approach. In particular I take issue with their rejection of the argument that a large proportion of the UK population are not of working age, whereas new immigrants are largely young or working age such that they swell the (shrinking) working age population which contributes (proportionately) the majority to the economy and state coffers - so that dividing immigrant contributions over the whole population is unfair because they are largely not addding to the dead wood of the non-working populace (who actually cause most of the costs to the state). The report says:

Arguments in favour of high immigration to defuse the “pensions time bomb” do not stand up to scrutiny as they are based on the unreasonable assumption of a static retirement age as people live longer and ignore the fact that, in time, immigrants too will grow old and draw pensions. Increasing the retirement age, as the Government has done, is the only viable approach to resolving this issue...

 Lord Turner argued that as people live longer, it is reasonable to assume that the extra years of life are divided between working years and retirement so as to keep roughly stable the proportions of life spent working and retired. Under this assumption, half of the projected increase in the dependency ratio disappears, when compared with the simplistic case in which the retirement age stays unchanged.

First of all I'd like to make clear that it is generally considered that for every additional year of life expectancy you can expect at best 6 months of relative health and 6 months of ill-health such that the policy of incrementally increasing the retirement age with life expectancy is basically aiming to work the populace until they are sick and to erode the few years of healthy retirement they might otherwise have expected*. It is also worth noting that immigrants can have a tendency to return to their country of origin after a few years. So while it is true that increasing the working age population will increase the number of retired people eventually (although to a lesser extent in the first generation due to decreased life expectancy compared to the UK population as a whole) it is still more sustainable in the short term than increasing the retirement age until people are being worked right to their death beds (in order to pay for the current older generation's nice early retirements at 60-65yrs old with over 10 yrs of life expectancy). 

In this vein, if we're going to talk about how much immigrants add in 'per capita GDP' we have to compare them to other members of the population - old people or the unemployed for instance - what do they cost in per capita GDP?  Averaging over a homogeneous UK 'indigenous' population is completely misleading because compared to significant proportions of the UK population immigrants use much lower poroportions of national expenditure.  The question should be how many 'indigenous' people does each immigrant support? And 'per capita GDP' can't answer this.

To look at it another way, if we consider a British person who contributes exactly the average per capita GDP to the country, are they having zero effect on the country or a net benefit? According to the 'per capita GDP' measure of economic contribution they are giving nothing to the country - despite working, paying taxes etc. - whereas common sense shows that they are helping to pay for those people who are a net cost to GDP (the economically inactive like the old, the young, the sick, the unemployed).


* Another gift from 'The Most Selfish Generation'

BBC distorting the news

This story was widely reported in the news today:

Preventable diseases in children are reaching epidemic proportions that could see a generation dying before their parents, doctors at a leading children's hospital have warned.

But this story is obviously related to this BBC documentary:

With unprecedented access to Alder Hey Children's Hospital in Liverpool, Panorama meets the kids and the paediatricians treating them, and follows them home in an attempt to uncover the root cause of their problems. Reporter Richard Bilton soon discovers that some of the basic health messages from the doctors are not getting through to the parents.

So either Alder Hey have been sending out press releases to coincide with BBC documentaries or the BBC have done so themselves, either way it is a real distortion of the news agenda for the day to present this story without pointing out the BBC's role - unfortunately this seems to be more and more common. A particularly stark example can be seen when the Today programme interview someone then the news bulletin seconds later reports a throwaway comment (often the result of bizarre questions and extensive badgering all designed to get a specific response) as if it is some groundbreaking announcement (normally quoting it out of context).

So today's health news was dominated by essentially an advert for a BBC documentary. Maybe there was something worth saying but the media really need to be more transparent about what is driving the news agenda. 

Dick swinging braggadocio

As I noted last year:

If swine 'flu turns out to kill a lot of people this Autumn then Jenkins should really be forced to confront his words. Of course, it probably won't, further inflating his dick swinging braggadocio, until we finally do get a pandemic viral illness (which we will eventually) - when he'll be clamouring to know why more wasn't done. Ah, the privilege of consequence free comment pieces, the life of a journalist is so easy - you get to feel so important while doing fuck all.

 As I feared the colossal arsehole has taken the fortunate avoidance of a pandemic flu as further proof of his omniscience:

This is why people are ever more sceptical of scientists. Why should they believe what "experts" say when they can be so wrong and with such impunity? Weapons of mass destruction, lethal viruses, nuclear radiation, global warming … why should we believe a word of it? And it is a short step from don't believe to don't care.

Why indeed should anyone pay attention to scientists and doctors when our always right Dr Simon Jenkins is there to keep us informed. What was that about AIDS again Simon?

"Aids has been confined largely to homosexuals and drug abusers, whose activities put them at risk of blood contamination and leave them vulnerable to lethal disease. There are some Aids cases outside the “high-risk” groups, but numbers are tiny: 60 at most in Britain. As far as Britain is concerned, the plague appears to be passing."

Don't blame the system for winter travel chaos. Stay put

Simon Jenkins says:

Hypermobility is now the opium of the people, an obsession that wrecks communities and planet. There are no free trips.

My solution to winter travel chaos? Don't travel. Stay indoors. Build a fire. Live and shop within walking distance of civilisation. Associate with neighbours. See distant relatives some other time of the year. Above all, do not complain if you insist on laying siege to motorways, stations and airports and the weather or the labour force let you down, as they do every year. It is not their fault, it is yours for being there.

I really don't know why people insist on not being London based journalists telecommuting from home.

If a hospital visit requires a drive of 50 rather than five miles, the NHS does not pay but someone does; indeed everyone does.

On the plus side, when you get to the 50 miles away hospital the economies of scale that entails mean that there might actually be some doctors and services there to provide you with at least a minimally effective service...that's if the doctors are allowed to get to work despite the fear of offending metropolitan pseudo-intellectuals.

Don't get sick this Christmas Dr Jenkins...and if you do don't you dare come to my hospital and screw up my already crappy Christmas day.

Dr Simon Jenkins

Dr Jenkins shares his well informed views of how trivial swine 'flu is:

...a condition correctly diagnosed by a Dulwich 12-year-old during the initial outburst of hysteria in May as "like a cold"

...the one thing not to take is Tamiflu...People should take an aspirin.

After all, who are you going to trust, doctors and scientists who have dedicated their lives to studying and treating disease, trying their best to plan and advise based on incomplete information, or some bloke in the pub?

If swine 'flu turns out to kill a lot of people this Autumn* then Jenkins should really be forced to confront his words***. Of course, it probably won't, further inflating his dick swinging braggadocio, until we finally do get a pandemic viral illness (which we will eventually) - when he'll be clamouring to know why more wasn't done**. Ah, the privilege of consequence free comment pieces, the life of a journalist is so easy - you get to feel so important while doing fuck all. Reminds me a little of the greatest intellectual struggle of our time.

EDIT: Heh, Gimpy got there first, pointing out that aspirin shouldn't be used in children, although there are plenty of other errors tackled in the comments to Jenkins's article. Also jonnyhead covers it and the Times's Mark Henderson.


* I really hope it doesn't, not least because it'll mean I have to deal with the consequences at work as everyone in the NHS goes off sick or to look after their children, leaving me with a massive workload and lots of really sick patients trying their hardest to infect me.

** And, I'd be willing to bet, making demands that health workers and/or other people (e.g. patients or healthy people depending on whether he's caught it) risk their own health to preserve his.

*** According to Gimpy, it would appear he's already been wrong about another viral epidemic - so it looks like it probably wouldn't bother him. Here's Jenkins on AIDS/HIV:

"Aids has been confined largely to homosexuals and drug abusers, whose activities put them at risk of blood contamination and leave them vulnerable to lethal disease. There are some Aids cases outside the “high-risk” groups, but numbers are tiny: 60 at most in Britain. As far as Britain is concerned, the plague appears to be passing."

A Million Women Drinking

Some data from the Million Women Study (of women aged over 50) has caused some headlines today:

A glass of wine each evening is enough to increase your risk of developing cancer, women are being warned.
Consuming just one drink a day causes an extra 7,000 cancer cases - mostly breast cancer - in UK women each year, Cancer Research UK scientists say.

These reports are based on this study and press release. I've graphed some of their data (top right, 95% floated** CI). I think it is clear that the difference between a drink a day and less than 2 drinks a week (this was the reference group because non-drinkers often includes ex-alcoholics or those who have given up because they are already sick) is less than convincing (obviously it is difficult to interpret given that both the upper end of the 3-6u group and the lower end of the 7-14u group cover around 1u/day).

The claim that "each additional drink regularly consumed per day may account for approximately 15 excess cancers per 1000 women up to age 75" is actually based on a regression on the average amount of alcohol consumed in each category* - this data is represented in the middle right graph (as above but with mean alcohol, a regression line, excluding non-drinkers, and 95% CI). We can see that average consumption in neither group is conveniently near an average consumption of 1 drink (10g)/day.

It is clear that the regression is strongly driven by the heaviest alcohol consuming group, with a shallower regression being indicated if you exclude these subjects, and this highlights the limits of doing a regression analysis and then reporting the increased risks per unit of alcohol, since any non-linearity can make the linear regression coefficients misleading (such that while the regression line may describe a Y% risk for every X units, the data may still not support a statistically significant Y% increase for the first X units drunk).

It is always worth being circumspect when dealing with epidemiological data that produces very small risks, because we cannot know that every confounding variable has been accounted for in what is simply an observational study. Look at the zero alcohol consumption group (this would not actually be zero since 7% of these were actually drinking alcohol by the 3-year followup, but they don't provide the mean data), looks like there is something different between these individuals and those with minimal alcohol consumption - but this is not captured in the data (the relative risks have already been adjusted for available confounding variables).

I'm not sure why my estimates of additional risk per 10g/day are so much less than the study (obviously my regression is Mickey Mouse but it fits nicely, and it doesn't seem to be due to me not using log-linear regression either) - I get less than 1.05 relative risk (as you can see from the graph), their estimate of 15 additional deaths per 1000 women is around a 1.13 relative risk, although it appears that they are only include those cancers with an increased risk from alcohol associated with them, i.e. they don't include the lives saved by alcohol preventing lymphoma, thyroid, and kidney cancer!

If we look at the figures they report in the study, they say that there is an incidence of 118 cases of cancers that alcohol increases the risk for (oropharynx, oesophagus, larynx, rectum, liver, breast) per 1000 women up to age 75 years, and by drinking 10u/day this risk is up to 133 per 1000 women (which is where I got the 1.13 relative risk from)***. Since these cancers made up around half of those in this study we could estimate that the overall cancer risk for women up to 75 years is 236 per 1000, applying our approximate overall increase in cancer risk of 1.05 we get an extra 12 cancers per 1000 women, or an increase in absolute risk of cancer of 1.2% - that is, drinking 10u/day means that the chances of you getting cancer before you are 75, which is 24% anyway, goes up by another 1.2%.

Interestingly the data suggest that the increased risk in cancers of the upper aerodigestive tract (larynx, oropharynx, oesophagus), which are some of the cancers increased in incidence with alcohol consumption in this study (the others being liver, rectum and breast cancer), is due to a synergistic effect with smoking tobacco (see their figure 4 - bottom right) - and this may mean the study overstimates the risk of alcohol - or rather, it fails to highlight that some of the apparent additional risk of alcohol only applies if you also smoke (it would be possible to control for this using covariates if smokers and non-smokers were modelled seperately).

* A unit is 8g alcohol, nowadays many wines and beers a sufficiently strong that they contain 10g per serving (small glass, half a pint) and this study uses 'a drink' to mean 10g alcohol.

** These confidence intervals are based on a 'floating absolute risk' model which is controversial and results in narrower CIs than conventional techniques.

***This is dodgy, to multiply the 118 cases of cancer by the estimated relative risk at 10u/day of 1.13 (which is what they seem to be doing) would only be valid if the 118 cases was from women in the lowest risk group - those drinking <= 2u/week - but we know that many women do drink more than this (nearly half in this study), and the overall cancer rate therefore already includes this extra alcohol related risk. However, if I adjust my above figures to account for this it doesn't make much difference - giving an additional 11 cancer per 1000 women, and thus absolute increased risk of 1.1%.

Johann Hari on free speech

Writing in the Independent:

Last week, I wrote an article defending free speech for everyone – and in response there have been riots, death threats, and the arrest of an editor who published the article.

Read it all.

Briffa demented loon: Official

In an apparent effort to ensure that no one is in doubt about his status as a complete nutjob following his comments on MMR and skin cancer, John 'SucroGuard' Briffa is accusing the charity Diabetes UK of deliberately trying to destabilise patients' blood sugar in order to increase the amount of medication they use in order to benefit BigPharma. You couldn't make this deranged shit up:

"Diabetes UK is the UK’s largest and most prominent diabetes charity...However, I’m doubtful that Diabetes UK is fulfilling its brief in this respect, seeing as it continues to suggest that diabetics should include starchy carbohydrates which every meal (see herefor more on this)...Yet, these starchy staples break down into sugar, and some of them can release their sugar quite quickly into the bloodstream too. And if we eat them in quantity, like we often do, that only adds to their disruptive effects. Now, what rationale is there for diabetics to include “at each meal” foods that are disruptive to blood sugar?...However, I reckon there’s another, far more relevant way of interpreting this sentence which goes something like: “The more starchy carbohydrate you eat, the more out-of-control your blood sugar level will be, the more ‘diabetic’ you will be, and the more likely you are to start to take medication for this or to need to increase your medication regime.” Remember the advice to eat generally sugar-disruptive starchy carbs with each meal comes from the UK’s largest diabetes charity which, it says, campaigns for “better standards of care for diabetics”.
What sort of care is it referring to, do you think? Because on the face of it, it doesn’t look like nutritional care is part of its remit. And if that’s the case, maybe what’s being referred to here is medical care including medication...I don’t want to come across unduly cynical, but is it right that a diabetes charity should have a less-than-transparent financial relationship with the drug industry. And is it right that this charity should be giving nutritional advice that, at the end of the day, looks likely to benefit the pharmaceutical industry. And after all of this, should it then go on to partner with that pharmaceutical industry in ‘research’ highlighting the need for people to take their diabetes medication. Or did I miss something?"

Absolutes versus rates

This post on talking philosophy highlights another example of journalists willfully using absolute figures and using these to calculate meaningless headline statistics ('mobile phone thefts up one billion % since 1980!!!') even when the sensible rate figures have been provided and their significance explained. Do they not understand or just not care?

Creationism from the BBC Natural History Unit

On nullifidian:

"BBC (i.e. taxpayer) provided webcams at the creationist Noah’s Ark Zoo Farm near Bristol...Oddly enough, these webcams are still advertised within the “nature features” part of the BBC Bristol web site. I guess they haven’t got around to re-organising the web site since the supernatural became a part of everyday existence."

"...the deaths of these five women is no great loss"

Want more reasons to hate vile Daily Mail columnist Richard Littlejohn? Then look here.

"You can prove anything with facts"

Just read this in the Telegraph:

"What Miss Smith means is that crime measured by the British Crime Survey has fallen; and while many statisticians claim this to be the best measure of offending, it appears to bear little resemblance to reality."

Reminded me of this:



"I'm not interested in facts, I find they tend to cloud my judgement"