10 noteworthy medical reversals for doctors
M3 India Newsdesk Jul 19, 2019
A recent analysis of more than 3000 randomised control trials published in leading medical journals identified 396 medical reversals contradicting older, low-value medical practices that can be eliminated or replaced with either a low-cost, less invasive, better or equivalently effective intervention.
It is important to eliminate low-value practices that prove ineffective and cost more than other drugs or treatments that prove as effective. [1, 2, 3] This is where medical reversal findings based on randomised controlled trials (RCTs) come in and enable doctors provide high-quality treatment.
Here we update you on 10 remarkable medical reversal findings published in the Journal of the American Medical Association (JAMA), the Lancet, and the New England Journal of Medicine (NEJM).
Fish oil does not reduce the risk of heart disease
That consuming fish oil for n−3 polyunsaturated fatty acids helps lower cardiovascular mortality and morbidity, is a common medical understanding. However, the same is not true; says a study titled N–3 Fatty Acids in Patients with Multiple Cardiovascular Risk Factors, published in NEJM (2013).[4]
The randomised trial was conducted on patients who had no history of myocardial infarction but had several cardiovascular risks. They were given fish oil capsules and systematic efforts were also made to keep the risk factors under control, while also optimising medical treatment. However, the study reported no major benefit of n−3 fatty acids in cutting down the chances of hospitalisation for cardiovascular causes or death from cardiovascular issues.
Single dose of oral opioids no better than aspirin or ibuprofen for ED patients in pain
A study reported no major differences in pain reduction between adult patients given opioids and those given non-opioid analgesics, both in the emergency department (ED).[5]
The study questioned the choice of opioids and compared the pain levels after treating a group of ED patients in acute pain with a combination of ibuprofen and acetaminophen, and another similar group with 3 different combinations of opioid and acetaminophen analgesics. They concluded that the combination of ibuprofen and acetaminophen (paracetamol), which are far safer, may work just as well as any opioid.
Clearing the house of mites and other possible triggers won’t prevent asthma attack
Any practitioner, besides prescribing medicine, would recommend simple practices, such as changing bed sheets or vacuuming your house regularly in order to prevent growth of pests and dust mites, which often act as triggers for asthma.
A randomised clinical trial was conducted for JAMA to check if professional pest management in the house along with pest management information could reduce mouse allergens and bring down asthma morbidity among patients of different ages.[6] And if it was any better than only providing them pest management education. Unfortunately, the researchers found no significant difference between the two. Asthma patients, whose homes were cleaned for pests by professionals, did not experience a reduction in the frequency of asthma attacks.
Wearable technologies do not help lose weight
People who want to lose weight often use wearables to keep a track of their calories burnt, number of steps and more. Yes, seeing a number to the efforts one makes can be motivating, but researchers say, it has no role to play in weight loss.
A study by Jackicic et al. for JAMA questioned the notion that technology-enhanced weight loss intervention (with wearable device) can help lose more weight when compared to a standard behavioural weight loss intervention.[7] The study involved observing results of close to 500 people on a weight loss mission. However, the ones with technology-enhanced weight loss intervention lost lesser weight, proving the belief wrong.
Physical therapy should be tried before surgery for torn knee meniscus
As you know, a torn knee meniscus can be quite painful and so, most surgeons recommend surgery. Even patients prefer it instead of waiting for physical therapy to work. But could physical therapy have helped with pain as much as surgery? Finding an answer to this question was the objective of the randomised controlled trials-based study titled Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis published in NEJM.[8]
In this intention-to-treat study and evaluation, the researchers had assigned arthroscopic partial meniscectomy to a group of patients with a meniscal tear and knee osteoarthritis and another group with the same condition to physical therapy. Patients from both the groups were given the option of switching to the other treatment if need be. However, they concluded that there was no notable difference in their functional status or pain, with either treatment. And since patients’ discretion was allowed, they also saw only 30% of the patients from the physical therapy group opting for surgery within 6 months. So, recommending physical therapy would be better before taking a step toward surgery.
If a pregnant woman’s water breaks, the baby need not have to be delivered immediately
The Lancet published a study that aimed to find out if birthing in singleton pregnancies, when the membrane ruptured close to the term, reduced neonatal infection without increasing the chances of possible morbidity.[9]
The PPROMT trial involved women with singleton pregnancies, without any signs of infection, but had ruptured membranes before the ideal gestation period of 37 weeks. The women were advised immediate delivery or assigned to expectant management as per a computer-generated randomisation.
The findings were that the group assigned to expectant management had a greater chance of antepartum or intrapartum haemorrhage, intrapartum fever, need of postpartum antibiotics and an extended hospital stay. However, the group reflected a lower risk of caesarean delivery.
Hence, the conclusion was that if signs of infection were not found or there was no foetal compromise, expectant management along with supervision for maternal and foetal well-being should be practiced in such women instead of opting for delivery.
Neonatal vitamin A supplementation does not lower mortality rate in newborns
Low-income countries were observed to have vitamin A deficiency in neonates and high mortality rates. Hence, supplementation to neonates at birth is practiced to lower the mortality rate. However, a study by Edmond et al. provides reverse findings.[10]
The trial was performed on two groups of infants, of which one was placed on Vitamin A supplements and another was given placebo. The findings say that mortality rate between the two groups could not be reduced; neither in the first 6 months, nor in the first 12 months of the life of infants. Even a Cochrane review by Keats et al. is inconclusive about positive effects on mortality among infants during the first 6 months or 12 months, using vitamin A supplementation at birth.[11]
Sertraline or mirtazapine does not help for depression in dementia/Alzheimer’s patients
For older patients with dementia or Alzheimer’s disease, sertraline and mirtazapine are considered as the first-line clinical treatment for depression. However, a study by Conjee et al.[12, 13, 14, 15] introduced reverse findings for the practice.
The trial conducted for the study showed that neither of the drugs given for depression, to patients with Alzheimer’s disease, made their condition better than those given placebo. This was concluded with the logic that depression for such patients may have different mechanisms when compared to that in general patients of depression. A review by Orgeta et al. also reiterated the findings, stating that they did not find a remarkable drug-placebo difference for symptoms of depression.[16]
Menopausal hormone therapy does not help prevent health outcomes or risk of death from cardiac diseases, stroke, or cancer
Postmenopausal Hormone Replacement Therapy (HRT) was believed to delay age-related diseases and was hence, prescribed to women showing signs of menopause. A reversal finding by Manson et al. states otherwise.[17]
Researchers checked the various health effects of HRT on postmenopausal women and deduced that there are several complexities attached to the treatment. However, when the treatment during the trial was compared to placebo, they found that HRT was not a recommended intervention to prevent chronic ailments that come with age.
Epidural corticosteroid injections for lumbar central spinal stenosis don’t impact pain, function, and likelihood of surgery
Epidural glucocorticoid injections are often prescribed to treat symptomatic lumbar stenosis, a related disability and moderate to severe leg pain, among various other conditions.[18] But going by the increasing usage and costs, Friedly et al. conducted a study based on the LESS trial to verify if the same was really effective.[19,20]
The trial design compared the efficacy of glucocorticoids plus anaesthetic injections and injections of anaesthesia alone. However, the RMDQ scores (representing functional disability) or the intensity of pain at 6 weeks showed no major differences. The conclusion hence, was that epidural corticosteroid injections don’t necessarily help the symptoms of spinal stenosis, nor do they bring down the chances of surgery.
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