Robert Goulden
@emrobg.bsky.social
Emergency physician | Epidemiology PhD student | Medical Flashnotes app creator
Diuretics may well ⬇️mortality in HF, we just don't know. But not for the first time, 'meta-analysis of RCTs' has laundered ambiguity and weak methods into apparently solid conclusions from the top of the evidence pyramid (4/4).
November 18, 2024 at 4:48 PM
Diuretics may well ⬇️mortality in HF, we just don't know. But not for the first time, 'meta-analysis of RCTs' has laundered ambiguity and weak methods into apparently solid conclusions from the top of the evidence pyramid (4/4).
Now for the implausible mechanism. Of 12 deaths in the placebo arm, the commonest cause was cancer (4 deaths), vs. 1 cancer death in the diuretic arm. Anti-neoplastic effect of diuresis or random chance? You decide. (3/4)
November 18, 2024 at 4:48 PM
Now for the implausible mechanism. Of 12 deaths in the placebo arm, the commonest cause was cancer (4 deaths), vs. 1 cancer death in the diuretic arm. Anti-neoplastic effect of diuresis or random chance? You decide. (3/4)
First, the error. Cochrane mortality OR is based on 3/111 deaths w/diuretics vs. 12/110 w/placebo. But looking at the 3 source RCTs, there are in fact *4* deaths in the diuretic arm. Adding this, the OR remains just about 'significant', 0.30 (0.10-0.98), but very fragile (2/4)
November 18, 2024 at 4:48 PM
First, the error. Cochrane mortality OR is based on 3/111 deaths w/diuretics vs. 12/110 w/placebo. But looking at the 3 source RCTs, there are in fact *4* deaths in the diuretic arm. Adding this, the OR remains just about 'significant', 0.30 (0.10-0.98), but very fragile (2/4)
It was all totally wasted. The findings were wrong and the net contribution to scientific understanding was negative. Publish or perish, ultimately pushed by funders and institutions, is driving a toxic culture of scientific waste. We have to stop. 5/5
November 12, 2024 at 3:21 AM
It was all totally wasted. The findings were wrong and the net contribution to scientific understanding was negative. Publish or perish, ultimately pushed by funders and institutions, is driving a toxic culture of scientific waste. We have to stop. 5/5
Collectively the individual observational studies (plus the SRs, and the SR of the SRs) represents at least 10s of thousands of labour hours from researchers, ethics panels, funding reviews, journal reviewers etc., and a large amount of $$$. 4/
November 12, 2024 at 3:21 AM
Collectively the individual observational studies (plus the SRs, and the SR of the SRs) represents at least 10s of thousands of labour hours from researchers, ethics panels, funding reviews, journal reviewers etc., and a large amount of $$$. 4/
Once again we have to ask: what was the point of this observational research? There was an obvious risk of unmeasured confounding, and none of the studies had a way to address this. But they published anyway! 3/
November 12, 2024 at 3:21 AM
Once again we have to ask: what was the point of this observational research? There was an obvious risk of unmeasured confounding, and none of the studies had a way to address this. But they published anyway! 3/
Since 2020, at least 3(!) systematic reviews on this question (plus an SR of the SRs!). Pooled results were 0.65 (0.51-0.8), 0.71 (0.59–0.85), and 0.71 (0.63-0.79). There was an obvious risk of confounding by indiction: sicker patients -> more difficult IV -> IO . 2/
November 12, 2024 at 3:21 AM
Since 2020, at least 3(!) systematic reviews on this question (plus an SR of the SRs!). Pooled results were 0.65 (0.51-0.8), 0.71 (0.59–0.85), and 0.71 (0.63-0.79). There was an obvious risk of confounding by indiction: sicker patients -> more difficult IV -> IO . 2/