Preventing heart disease – a continuing story

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Public Health England (PHE) is the organisation responsible for the oversight of all preventive activity in England. This ranges from vigilance for infectious disease outbreaks and epidemics, through immunisation programs, to advice and support for prevention in general practice – including that relating to non-communicable diseases, especially circulatory disorders.

With the increased prevalence of cardiovascular disease in an ageing population, PHE has been reviewing investment in its prevention strategy. (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/749866/CVD_ROI_tool_final_report.pdf)

As in Australia, since the mid-1960s, deaths in middle age from heart attack have decreased in England by well over 50 per cent. This is attributable, almost equally as best we can tell, to improvements due to primary prevention, most notably dramatic downturns in smoking, and to improved treatment.

Falls in the rate of ‘sudden death’, which are substantial, are an obvious place where primary prevention is working. But the evidence is difficult to collect and assess. As Earl Ford, an American epidemiologist, and Simon Capewell, a clinical epidemiologist from Liverpool University in the UK, wrote in 2011 (www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031210-101211), “Changes in risk factors may explain approximately from 44 per cent to 76 per cent of declining CHD mortality and treatments may explain approximately from 23 per cent to 47 per cent. Thus, both prevention and treatments have contributed immensely to the decline in CHD mortality.”

Nevertheless, despite these advances, cardiovascular disease remains a major problem. This year, according to calculations from the Australian Heart Foundation, based on data from the Bureau of Statistics, about 8,000 Australians will die from a heart attack.

Heart attack death was previously restricted to economically advanced societies, but it now spread widely through economically developing, and even the poorest, nations. Here, death from heart disease follows the pattern we saw in Australia before the decline in mortality began in the 1960s, namely, middle-aged men and women, rather than the elderly, being at serious risk. Our effectiveness in managing infectious disease in those less affluent countries means that those people are now more prone to the degenerative diseases familiar to us.

What is the scope for prevention in clinical practice? A survey this year by the Heart Foundation found: “One in two Australians who have had a heart attack [and there are about 40,000 of them under 55] continue to smoke. Of these, close to 40 per cent did not even attempt to quit … almost one in four have failed to regularly monitor their blood pressure levels. More than a quarter are not having regular cholesterol checks. Around one in three tried to increase their physical activity levels or lose weight, however failed to maintain the changes.”

In clinical practice, prevention of death – and disability – from cardiovascular disease is a deep concern –a frequent reason for consultation and prescription and a major consumer of time in general practice.

Despite the lack of information about outcomes, Public Health England, with help from the University of Sheffield, examined the available evidence for what works and how much it costs (including general practitioners’ time). PHE settled on five interventions – detection and treatment which had merit both in terms of medical outcome and cost for:

Hypertension
Atrial fibrillation (anticoagulation)
Hypercholesterolaemia
Diabetes
Non-diabetic hyperglycaemia (‘pre-diabetes’)
Chronic kidney disease.

Based on a 2014 health survey in England, the prevalence of individuals aged 16+ with one or more of these high risk conditions was 49 per cent.

The best evidence concerning effective interventions for each condition was then assembled, along with data on the cost of the most effective interventions and the duration of likely effect following the interventions. This information was combined into a package which allows individual practitioners to calculate the local costs and benefits of these interventions in their practice.

“The single intervention with the highest net total savings in the short term (years 2-5) is to optimise the proportion of people taking statins… a saving of £700 million in England [total population: 45 million] by year five. However, in the long term (20 years), optimising antihypertensive treatment is the single intervention predicted to save the most money (over £2 billion)… but most of the lifestyle interventions are not cost-saving over 20 years.”

What may we conclude for Australia? Among the preventive interventions for managing cardiovascular disease in general, and heart disease in particular, we are committed to long-term care for optimal effect. This may not become obvious for 20 years, but this is not to gainsay it.

Preventive treatment requires a philosophy of long-term care and support to be effective.

Brain mapper finds hidden region

World-renowned cartographer of the brain, Scientia Professor George Paxinos AO from Neuroscience Research Australia (NeuRA), has discovered a hidden region of the human brain.

The region is found near the brain-spinal cord junction and Professor Paxinos has named it the Endorestiform Nucleus.

Professor Paxinos suspected the existence of the Endorestiform Nucleus 30 years ago but has only now been able to see it with better staining and imaging techniques. Commenting on this discovery, Professor Paxinos said it’s like finding a new star.

“There is nothing more pleasant for a neuroscientist than identifying a hitherto unknown area of the human brain. In this case, there is also the intrigue that this area is absent in monkeys and other animals,” said Professor Paxinos, adding, “there have to be some things that are unique about the human brain besides its larger size, and this may be one of them.”

The discovery of new brain regions helps researchers to explore cures for diseases including Alzheimer’s, Parkinson’s disease and motor neuron disease.The Endorestiform Nucleus was noticed when Professor Paxinos introduced the use of chemical stains, combined with imaging techniques, in the production of his latest atlas.

The Endorestiform Nucleus is located within the inferior cerebellar peduncle, an area that integrates sensory and motor information to refine our posture, balance and fine movements.

“I can only guess as to its function, but given the part of the brain where it has been found, it might be involved in fine motor control,” said Professor Paxinos.

Many neuroscientists researching neurological or psychiatric diseases, in humans or animal models, use Professor Paxinos’ maps as guides for their work.

An increasingly detailed understanding of the architecture and connectivity of the nervous system has been central to most major discoveries in neuroscience in the past 100 years.

“Professor Paxinos’ atlases, showing detailed morphology and connections of the human brain and spinal cord, provide a critical framework for researchers to test hypotheses from synaptic function to treatments for diseases of the brain,” said Professor Peter Schofield, CEO at NeuRA.

“It is truly an honour for Elsevier to be continuing Professor Paxinos’ legacy of publishing with us,” said Natalie Farra, Senior Editor at Elsevier. “His books are world-renowned for their expertise and utility for brain mapping, and for their contributions to our understanding of the structure, function and development of the brain.”

Professor Paxinos is the author of the most cited publication in neuroscience and another 52 books of highly detailed maps of the brain. The maps chart the course for neurosurgery and neuroscience research, enabling exploration, discovery and the development of treatments for diseases and disorders of the brain.

The discovery of the Endorestiform Nucleus, is detailed in Professor Paxinos latest book titled Human Brainstem: Cytoarchitecture, Chemoarchitecture, Myeloarchitecture.

[Correspondence] Comparing estimates of spending on health and HIV/AIDS

We commend the Global Burden of Disease (GBD) Health Financing Collaborator Network (April 17, p 1799)1 for publishing HIV spending estimates. However, we are concerned that some readers could interpret the GBD’s reported estimates to mean that the global HIV-resource needs have been met.

[Correspondence] Gender bias in publishing

We applaud Jamie Lundine and colleagues1 for highlighting the systemic gender bias and structural sexism in academia. We welcome the notion that “the gendered system of academic publishing is both a reflection and a cause” of biases in academia.1 The call to journals and publishers to align their actions with gender equality and broader social justice movements within and outside academia is crucial and timely.

[Perspectives] The business of academic publishing: “a catastrophe”

As I watched Paywall: The Business of Scholarship, I was taken back 30 years to when I thought for the first time about the business aspects of academic publishing. I was an assistant editor at the BMJ, and the editor asked me to join a meeting with a group of rheumatologists who wanted a share in the Annals of Rheumatic Diseases, a journal we owned. “We do the research published in the journal”, said one of the rheumatologists. “We do the peer review, we edit the journal, we read it, and we store it in our libraries.

Retraction of a journal article doesn’t make its findings false

The American Medical Association recently retracted six papers co-authored by food consumption and psychology researcher, Brian Wansink, in three of its journals. These studies include two showing that large bowl sizes encourage us to eat more, and that shopping when hungry leads us to buy more calorie-dense foods.

A prolific academic researcher, Wansink has provided many thought-provoking ideas about the psychology of food consumption through more than 500 publications which have been collectively cited more than 25,000 times.

His research has shown that people will eat a lot more from a bottomless soup bowl; they will eat more from larger portions, even if it is stale popcorn or food served in a dark restaurant; and they will eat less if a portion is made to appear larger using visual illusions.

Retractions are a permanent means by which journals endeavour to preserve the integrity of scientific literature. They are typically issued for some form of misconduct, but it does not necessarily mean the results are false.

Are retracted studies false?

A number of challenges have been made against more than 50 of Wansink’s publications. At present, 15 corrections have been published and 13 retractions have been made.

The retractions follow a range of allegations of misconduct including autoplagiarism (copying your own work), data mismanagement and data manipulation. But none of this means Wansink’s results are entirely discredited.

The American Medical Association made its retractions based on Cornell University (Wansink’s employer) being unable to provide an independent evaluation in response to an Expression of Concern regarding Wansink’s studies issued in May.

The absence of evidence does not prove his results are false.

Science relies far more on whether results are repeatable than retractions. And many of Wansink’s results – including some which have been retracted – have been replicated.

Two of the most recently retracted studies showing that adults and children eat more from larger bowls form a part of a larger literature and have been cited nearly 300 times and 40 times respectively.

Multiple reviews of the scientific literature reveal that others have replicated the findings of Wansink and colleagues on how the plate or bowl size affects consumption.

In a meta-analysis I authored with others, the combined studies in this area show that doubling the plate size increases consumption by 40% on average. Though this is only the case if people are serving food onto the plate themselves. (Disclosure: this meta-analysis was published in a journal issue for which Wansink was one of the editors).

Replication is more important than retraction

The problem of reproducing findings in science is a much bigger issue than retractions. Retractions attract attention, but are relatively minor; replication does not attract attention, and is critically important.

The replication crisis facing social sciences, health and medicine suggests that 50% or more of published findings may not be repeatable.

In social science, a team replicated 100 studies published in three high-ranking journals. The results showed only 36% of the replications found statistically significant results, and the average size of the observed effects was half of that seen in the original studies.

Wansink has published more than 500 articles. If 250 of them prove to be false in the sense that the results cannot be replicated, then he is on par with social and medical science in general.

The retraction of thirteen of Wansink’s articles – some of which have been replicated by others – is a blip receiving much more attention than it deserves.

The high rate of replication failure arises, in part, from the arcane statistical approach used for analysing research data. In essence, researchers seek statistically significant findings. Statistical significance is typically defined as when the probability (p-value) of the observed data assuming there was no effect is less than 5%.

Journals and academics wish to publish novel, statistically significant results. They tend to ignore studies with null results, putting them in a file-drawer.

Replications that are successful add nothing new, and replications that fail (not statistically significant) are uninteresting to publishers albeit critically important to science.

A related problem is that academics may dredge through data and cherry pick statistically significant results, a practice called p-hacking.

The misconduct of journals and academics through their obsessive focus on statistically significant findings is widespread. If Wansink differs from others, it is in his disarming honesty admitting to data dredging in a 2016 blog post which attracted intensive scrutiny from his peers.

Science makes mistakes and missteps. The advances are achieved through new ideas and repeated testing.

Retractions may be important signals of reduced confidence in a finding, but they do not prove a finding false. This requires replication.

Science doesn’t provide certainty. Claims of absolute certainty made by authoritative figures are probably false.

As Tim van der Zee, one of Wansink’s lead detractors states on his website “I am wrong most of the time.” The challenge for scientists is to believe this.

Stephen S Holden, Adjunct Professor, Macquarie Graduate School of Management

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Endometriosis plan released

Australia has its first National Action Plan for Endometriosis, the painful condition that affects one in 10 Australian women.

Health Minister Greg Hunt said that the plan is designed to improve the quality of life of patients through better treatment and faster diagnosis, with the ultimate aim of finding a cure.

The Government is investing $1.2 million to help implement the Plan’s recommendations, taking the investment in the Plan to $4.7 million.

“Endometriosis is a chronic menstrual health disorder that affects around 700,000 Australian women and girls,” Mr Hunt said.

“It often causes debilitating pain and organ damage, and can lead to mental health complications, social and economic stress, and infertility.

“Many have suffered in silence for far too long, enduring diagnostic delays of between seven and 12 years on average.

The National Endometriosis Steering Group will oversee the implementation of the National Action Plan over the next five years.

Steering Group members include Dr Susan Evans, Janet Michelmore AO, Sylvia Freedman, Nola Marino MP, Jessica Taylor, Professor Peter Rogers, Professor Jason Abbott, and immediate past AMA ACT President, Professor Stephen Robson.

More information is available at http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-hunt095.htm

Medical Board backs down on naming doctors

The Medical Board of Australia has backed down on its plan to publicly name doctors who had been under investigation, regardless of whether any adverse finding had been made.

AMA President Dr Tony Bartone recently wrote to the Board Chair, Dr Joanna Flynn AM, and Chief Executive Officer, Martin Fletcher, to express concerns over the plan.

Dr Bartone said the AMA had “significant concerns” about the recommendation to publicly link disciplinary and court decisions to the registration details of doctors – regardless of whether the doctor has been found guilty of any transgression.

“The AMA is very concerned about the potential for medical practitioners to suffer discrimination as a result of being named in a previous tribunal proceeding, particularly where there was no finding against the practitioner,” Dr Bartone wrote.

The AMA was also concerned about cases where the issue was relatively minor or had occurred some years ago, where the doctor or their practice complied with the tribunal’s recommendations, and where other safeguards have been introduced to protect patients.

“In many cases, the public will not read the linked information but will assume that, because it has been linked by a reputable regulatory body, it is serious and of ongoing relevance,” Dr Bartone said.

“The AMA finds it difficult to comprehend that medical practitioners who are named in a tribunal procedure are offered less protection from discrimination than a person who has served a prison term.

“For example, the Commonwealth legislation would prohibit the Australian Health Practitioners Regulation Agency (AHPRA) from republishing information about persons who have been convicted of up to 30 months imprisonment.

“And yet, medical practitioners who have committed a minor transgression (even when they have taken steps to ensure the issue can never occur again), or where the practitioner is not found guilty, will have links to the disciplinary process listed against them in perpetuity. This seems palpably unfair.”

In late July, the Board announced that it would now only publish links to serious disciplinary decisions on the public register in the event of an adverse finding against the doctor.

“The Board has changed its position after listening to advice from many doctors and other stakeholders that this was not fair when no adverse finding had been made about the doctor,” it said in a statement.

[Comment] The gendered system of academic publishing

Gender is a sociocultural and economic concept and an institutionalised system of social practices that translates into different experiences and uneven advantages for men and women at the individual, organisational, and societal levels.1 This system manifests as the persistent gender pay gap, endemic sexual harassment,2 and the proverbial glass ceiling limiting women’s representation and advancement in social and economic life. Academia, including academic publishing, is not immune to this gendered system of social practices.

AMA House a perfect location for headquarters

AMA House was constructed throughout 1990 on a special 99-year lease block on the edge of what is known as the Parliamentary Triangle in Canberra.

The Parliamentary Triangle is the largely ceremonial precinct in the nation’s capital and straddles the part of Lake Burley Griffin where some of Australia’s most significant institutional buildings find their home on its banks.

The High Court, the National Gallery, the National Library, the National Science and Technology Centre (Questacon), the National Archives, the Treasury, Old Parliament House and, of course, Parliament House are all located in the Triangle – as is the Aboriginal Tent Embassy and Reconciliation Place.

Other Federal Government departments are also located either inside or close to the Triangle, with a smaller triangle within the precinct known as the Parliamentary Zone on the lake’s southern shore.

AMA House is located on the edges of the Triangle’s official boundary and within close walking distance to Parliament House.

It was a longstanding ambition of the AMA to have a national headquarters in Canberra.

The Federal Secretariat at that time had been working out of a building in Sydney owned since 1924 by the Australasian Medical Publishing Company (AMPCo, publisher of the MJA), but which was sold in 1989 to The University of Sydney.

During the construction period, Federal Secretariat staff occupied an office in Queanbeyan, on the NSW-ACT border just a few kilometres from where the organisation’s new home was being built.

During this period, the AMA also adopted a new national logo and launched a new national journal, Australian Medicine (this publication).

On March 7, 1991, AMA House was officially opened in Canberra by the highly esteemed biologist Professor Sir Gustav Nossal, who was/is also an AMA member.

At the time of its opening, Dr Bruce Shepherd was the AMA Federal President and Allan Passmore the Secretary General.

Once in its new home, the Federal Secretariat quickly created AMA departments with expertise in general practice, medical fees and medical insurance, public relations and communications, public health and hospital and health funding.

Staff for the most part were all located on the third and fourth (top) floors of the building.

In recent years, housing of staff was reduced exclusively to the fourth floor, with the third floor used for membership workshops and meetings of the Federal Council.

Offices were leased out to other organisations and businesses on the remaining floors.

With the sale of AMA House, the organisation retains naming rights and the exclusive lease of the fourth floor.

CHRIS JOHNSON

Pic: AMA House under construction.