Rehab Journal Review

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JAMA Internal Medicine, 30 March 2015

“An apple a day DOES NOT keep the doctor away” concluded this observational study from the US ‘Association between apple consumption and physician visits‘. The authors collected data from a cross-sectional survey of non-institutionalized people. Among other questions, the participants were asked if they eat at least one apple a day. Though the apple-eaters did not seem to have significant advantages over non-eaters in terms of avoiding doctor visits or hospitalizations, “apple eaters… remained marginally more successful at avoiding prescription medications”. Seems our ancestors were not completely off the mark.

Statistics learning point: “Association” mentioned in this study is NOT to be confused with “causation”.

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Cochrane Library, 12 March 2015

Cholesterol reducing statin group of drugs is a manufacturer’s delight. Except for the fact that there is no solid evidence to show they actually help reduce incidence of endpoints that matter- stroke and heart attack, they score most other check-boxes for the manufacturers:

1. Sell world-wide. No racial, regional limitation.

2. A day’s dose doesn’t cost much (just over Rs.4). Good chance people would continue to use.

3. Almost everyone beyond 40 years of age is now a potential buyer (for the rest of the life), thanks to “routine health check-ups” even for asymptomatic people.

4. It is easy to show efficacy in improving a surrogate end-point (cholesterol levels), to an extent that a Cochrane review ‘Lipid lowering efficacy of atorvastatin‘ updated this month “significantly increases the strength of the evidence… that atorvastatin decreases blood total cholesterol and LDL-cholesterol in… the commonly prescribed dose range. …Atorvastatin is more than three-fold LESS potent than rosuvastatin“. That last statement is likely to expedite the end of atorvastatin era, and the beginning of rosuvastatin era. Yet, the authors rightly point out that the “review update does not provide a good estimate of the incidence of harms associated with atorvastatin because included trials were of short duration and adverse effects were not reported in 37% of placebo-controlled trials”. We might never know the truth.

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Archives of Physical Medicine & Rehabilitation, March 2015

381 Epidural steroid injections don’t work; but they work. That’s the sort of self-contradictory conclusion from the authors of this Dutch pragmatic randomized trial “Epidural steroids for lumbosacral radicular syndrome“. When compared to “no-injection”, steroid injections seemed to do NO BETTER in reducing pain, but in a queer way resulted in better functioning and productivity, as assessed by SF-36. It is worth remembering that the productivity benefits were in Netherlands which is among the better places to live, and cannot be extrapolated to other countries.

Learning point: 1. if you plan to inject your patient with the aim of reducing pain, think twice, you might be causing more harm than benefit. 2. Read why pragmatic trials are pragmatic

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Spinal Cord, March 2015

209 There is no consensus on whether catheters could be reused for clean intermittent catheterization. Most manufacturers caution you to throw them off after single use. Authors of this cross-over trial in Malaysia have found that “reuse of CIC catheters for up to 3 weeks in children with neurogenic bladders…does not increase the incidence of symptomatic UTI“. That’s confirmation of what we’ve been practicing for long. Just need to check how far we could push the bar. The authors should have mentioned the type of catheter used at their center; it matters.

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Liked on twitter: Illustrative analogy for how our governments cook-up healthcare target achievement reports