On the Pulse

On the Pulse - 19th December 2008

Alexander Technique for back pain 
A randomized controlled trial in the BMJ investigates whether the Alexander Technique benefits patients with chronic back pain. Although often confused with manipulative therapies such as osteopathy, the Alexander Technique teaches people to become more aware of their everyday movements, and then abandon postural habits that cause problems. The interventions also included massage and exercise, but the Alexander component appeared to have the most benefit at 1 year, with median number of days in pain over 4 weeks dropping from 21 to only 3.

Malaria vaccine
A vaccine against malaria is finally showing promise, according to 2 papers in the NEJM. In a phase 2 study in children in Kenya and Tanzania, it was about 50% effective in preventing clinical malaria. In another study, a similar vaccine was safely administered to infants at the same time as triple vaccine without compromising the immune response to either. Why has the development of a vaccine taken so long? The short answer: it’s difficult to produce a lasting immune response against a protozoan parasite that is intracellular for most of its lifecycle. But there’s a fuller explanation here.

Ruling out elbow fracture
Deciding which patients require radiography can be difficult in emergency care, particularly with acute elbow injuries. These are common, and most will not include a fracture. A paper in the BMJ finds that if a patient can fully extend their elbow, this is almost enough to rule out significant bone injury: only 1.6% of adults and 4.2% of children could do so when they had a fracture. Conversely, patients who could not extend their elbow had an almost 50% chance of fracture, justifying radiography. An accompanying editorial points out that certainty is a luxury seldom afforded to emergency doctors, whose role is to manage risk appropriately. The difficulty lies in what to tell an anxious patient when doing so.

The economics of weight loss
Can you bribe people to lose weight? Yes, according to a study in JAMA. Economists often suggest that people tend to discount future gains (i.e. good health and long life) in favour of short-term gains (e.g. chocolate pudding). The study’s approach turns this logic on its head, either enabling people to profit directly from weight loss (the ‘deposit contract’ group) or making them eligible for a lottery win by meeting their weight loss target. After 16 weeks, the lottery group had lost 13 lb more than controls, and the deposit contract group had lost 14 lb more. At a cost of about $300 per participant over the 16 weeks, this is certainly more cost-effective than many anti-obesity medications.

Pressure ulcers
Treatment of pressure ulcers is difficult, slow, expensive, and often unsuccessful. Hundreds of wound care products and devices such as special mattresses are promoted, but very few have been evaluated in high-quality RCTs. A systematic review in JAMA assesses the situation, finding little reason to prefer one type of dressing over another, and no good reason to use powered mattresses instead of non-powered support surfaces, or to administer nutritional supplements or biological agents such as recombinant human platelet-derived growth factor. Despite the obvious need for good studies to establish the efficacy and safety of the many commonly used current treatments, Dr Lydgate wonders who will fund them.
 
Evidence-based beta-blockers
In RCTs, three beta-blockers – carvedilol, metoprolol and bisoprolol – improve survival in patients with heart failure due to left ventricular systolic dysfunction. But is this a class effect of beta-blockers, or are some more effective than others? Two database studies in Archives in Internal Medicine, one in elderly people eligible for both Medicare and Medicaid, the other of adults enrolled in two health-care plans, find little difference between individual beta-blockers in terms of survival, and a substantial benefit from treatment. Commentaries (here and here) suggest these observational studies need to be confirmed in randomized trials, but there are surely far more pressing questions for RCTs. The important thing is to make sure that patients who might benefit from these drugs are actually receiving them.

The right to health
December 10th marked the 60th anniversary of the Universal Declaration of Human Rights, and to mark the occasion, the Lancet has dedicated an issue to the concept of a right to health. The whole issue is worth a look, but if the concept of a right to health seems confusing or problematic, a good place to start may be a short but incisive piece by the Nobel prize winner Amartya Sen. He argues against thinking of rights solely with respect to legislation, or being bound by notions of feasibility – by saying that everyone has the right to life, we cannot and do not guarantee that they will not be murdered. Rather, by adopting something as a right, we are making a strong social commitment to it By taking action appropriately, we will advance the state of global civilization.

Mortality on Everest
The summit of Mount Everest is the highest point on earth – to some, it exerts an irresistible and potentially fatal attraction. The BMJ has a retrospective analysis of a remarkable Himalayan database maintained over 40 years in Katmandu, on causes of death in mountaineers. Overall, case fatality in people climbing higher than base camp was 1.3%; unsurprisingly, most occurred during attempts to reach the summit. Risk of death was 7 times higher in climbers than in sherpas and, when not caused by trauma, was associated with features of high altitude cerebral oedema (profound fatigue, cognitive changes and ataxia) and taking a longer time to reach the summit.