In the past, medical journals, pharmaceutical companies and researchers themselves have been criticized for publishing selectively only their positive results, that is to say, the results that they wanted to find. This is important because accentuation of the positive can easily mislead the medical profession into believing that a certain drug or treatment is much more effective than it really is.
On reading the New England Journal of Medicine and other medical journals, I sometimes wonder whether the pendulum has swung too far in the other direction, in accentuating the negative. To read of so many bright ideas that did not work could act as a discouragement to others and even lead to that permanent temptation of ageing doctors, therapeutic nihilism. But the truth is the truth, and we must follow it wherever it leads.
A recent edition of the NEJM, for example, reported on three trials, two with negative results and one with mildly positive ones. The trials involved the early treatment of stroke, the prophylaxis of HIV injection, and the treatment of angina refractory to normal treatment (a growing problem). Only the latter was successful, but it involved 104 patients as against 6729 patients in the two unsuccessful ones.
The successful trial involved the insertion of a device that increased pressure in the coronary sinus, the vein that drains the blood from the heart itself. For reasons not understood, this seems to redistribute the blood flow in the heart muscle, thus relieving angina. In the trial, the new device relieved and reduced angina symptoms, and improved the quality of life in the patients who received it compared with those who underwent a placebo-operation. The trial was too small, however, to determine whether the device improved survival, though even if it did not a reduction of symptoms and an improvement in the quality of life is worthwhile.
The trial of chemoprophylaxis of HIV was, by contrast, a total failure. The trial recruited 5029 young women in Africa who were given an anti-HIV drug in tablet or cream form, and others who were given placebos. The rate at which they became infected with HIV was compared, and no difference was found.
In large part this was because the patients did not take or use the pills or cream, though they claimed to have done so. A drug that few take is not of much use however effective it might be in theory, especially in prophylaxis rather than treatment. And this points to another problem of pharmaceutical research: in drug trials that require patients’ compliance with a regime, that compliance may be high during the trial itself (thanks to the researchers’ vigilance and enthusiasm) but low in “natural” conditions, when the patients are left to their own devices.
The trial of magnesium sulphate in the early treatment of stroke was also a failure. It had been suggested by experiments on animals that this chemical protects brain cells from degeneration after ischaemic stroke. It stood to reason, then, that it might improve the outcome in humans in ischaemic stroke, at least if given as soon as suspected.
Alas, it was no to be. The trial, involving 1700 patients, showed that the early administration of magnesium sulphate did not improve outcome in the slightest. At 90 days there was no difference between those who received it and those who had received placebo.
Is an idea bad just because it does not work? Could it be that those who discover something useful are just luckier than their colleagues? Perhaps there ought to be a Nobel Prize for failure, that is to say for the brightest idea that failed.
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