Faculty of 1000

Post-publication peer review

Archive for March 23rd, 2010

Placebo experimentation and LUTS

Posted by Callum Anderson on 23 March, 2010

A couple of interesting evaluations have made their way past my desk this week, both from Faculty of 1000 Medicine. The first evaluation is of a very interesting paper, originally published in German, which reports results of a questionnaire. The title of the paper is Uncontrolled placebo experimentation in a university hospital, and the results certainly shocked me (I wonder if they would have the same effect on a practicing physician?)

So what percentage of practitioners do you think would admit to regularly treating with placebos in a ‘university hospital’?

The paper reported that 72% of participants admitted to regularly using placebos.

And this despite only 62% of the same group believing that placebos worked “often” (as opposed to 3% – “forever”; 35% – “Sometimes”.)

All those with medical knowledge are aware that placebos do work, and often work better than drugs with active compounds. This paper had me digging through a 2008 copy of the BMJ and the paper [subscription required] entitled What is the placebo worth? in which David Spiegel put forward the case that the most significant part of the placebo is the doctor-patient interaction.

He says

Perhaps the ratcheting down of the time that doctors spend with patients and our modern overemphasis on procedures is “penny wise and pound foolish.” Patients might respond better to real as well as placebo interventions if they were associated with a good doctor-patient relationship.

So perhaps placebo treatment has a place in medicine for some conditions. Spiegel specifically notes that a patient with a condition such as irritable bowel syndrome might be best treated by a doctor with an empathetic ear and time to listen to their story.

I think we still have a tremendous amount to learn about placebos, and studies such as the one conducted by Bernateck et al. imply that despite this obvious lack of understanding their use in clinical situations is relatively commonplace. With more research, and a better understanding of placebos, they could represent a very useful alternative treatment. Perhaps in a case where the clinician has reason to reduce the daily dose of certain pharmacological treatments for some reason or another; or simply in a case where psychophysiological treatment is a more sensible option.

However, a hospital setting is not the right place for experimentation, especially when the results of this survey suggest an assumption amongst medical practitioners that patients typically exaggerate symptoms.

Keeping on the same track – well sticking to medicine at least – another important paper, evaluated in Faculty of 1000 by Julian Wan, concerns an interesting and ubiquitous clinical situation: women presenting with lower urinary tract symptoms (LUTS). This randomized-controlled-trial seeks to establish if any improvements to current diagnostic procedures can be made.

A recent trend in general practice has been for patients to present to their doctor much earlier than has been typical previously. This makes it very difficult for the doctor to diagnose the condition without sending off for formal testing or culture, and as a result, antibiotics are typically prescribed by symptom alone.

This paper looked at  309 non-pregnant women aged 18-70 all presenting with LUTS (dysuria, nocturia, cloudy/foul smelling urine etc.) The women were randomized into five management approaches: empirical antibiotics, delayed empirical antibiotics, targeted antibiotics, dipstick result or midstream urine analysis. It certainly covers an appealing research topic, especially as LUTS represent a very common clinical situation.

As Faculty of 1000 member Julian Wan says

For many practitioners, it is common practice to simply prescribe by symptom without formal testing or culture. There is surprisingly little published about this very common approach, and no large scale randomized trial based on symptom relief and ‘delayed’ antibiotic prescribing.

In a nutshell, the conclusion is that there is no advantage from the perspective of alleviating symptoms in sending out routine midstream urine samples. The approach put forward is empirical delayed prescription to reduce antibiotic use, and targeting with a dipstick test rather than sending the samples off to a lab.

What I really like about this paper is that it makes surprising conclusions, but uses a significant evidence based study to make them. A study like this certainly makes me think that there is still plenty of research to be made into other common conditions. Medicine can sometimes be prone to treat according to status quo, and perhaps with more evidence based research, we could learn to treat more effectively?


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