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《新闻周刊》最新文章快译:为什么你听到的医学信息几乎全是错的?  

2011-01-25 01:45:49|  分类: 读点英文 |  标签: |举报 |字号 订阅

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中文译文已独家授权译言网使用,谢绝转载。正式版本请参阅:http://article.yeeyan.org/view/203390/168474 , 已有多个批评注解。

以下草稿:

 

  
Why Almost Everything You Hear About Medicine Is Wrong

From:http://www.newsweek.com/2011/01/23/why-almost-everything-you-hear-about-medicine-is-wrong.html

by Sharon Begley 

 

为什么你听到的医学信息几乎全是错的?

作者:莎伦·贝格立 2011.01.24

 

If you follow the news about health research, you risk whiplash. First garlic lowers bad cholesterol, then—after more study—it doesn’t. Hormone replacement reduces the risk of heart disease in postmenopausal women, until a huge study finds that it doesn’t (and that it raises the risk of breast cancer to boot). Eating a big breakfast cuts your total daily calories, or not—as a study released last week finds. Yet even if biomedical research can be a fickle guide, we rely on it.

如果你追随健康研究的新闻,那么你危险了。先是说大蒜能够降低有害的胆固醇,然后,经过更多的研究,他们说不能。先说激素替代可以减少绝经妇女患心脏疾病的危险,然后经过大量的研究发现完全不是那么回事(反而会增加患乳癌的危险)。上星期他们又有报告,关于吃一顿丰盛早餐能或者不能削减每日摄取的卡路里。尽管生物学研究的结论如此反复无常,可我们还是会盲目的相信它。

But what if wrong answers aren’t the exception but the rule? More and more scholars who scrutinize health research are now making that claim. It isn’t just an individual study here and there that’s flawed, they charge. Instead, the very framework of medical investigation may be off-kilter, leading time and again to findings that are at best unproved and at worst dangerously wrong. The result is a system that leads patients and physicians astray—spurring often costly regimens that won’t help and may even harm you.

但如果错误的答案不是偶然而是经常性的呢?现在,越来越多对健康进行了彻底研究的学者做出了声明。他们指责道,不仅仅是那些独立研究出了这样或那样的问题,而是整个医学调查研究的整体框架都出现了失衡。导致屡屡发现问题,最轻微的问题至少是没有很好的论证,最严重的情况则是危险的错误。其结果是系统性的误导患者和内科医生——极力推荐的昂贵的养生法则完全没有用处,甚至可能是有害的。

It’s a disturbing view, with huge implications for doctors, policymakers, and health-conscious consumers. And one of its foremost advocates, Dr. John P.A. Ioannidis, has just ascended to a new, prominent platform after years of crusading against the baseless health and medical claims. As the new chief of Stanford University’s Prevention Research Center, Ioannidis is cementing his role as one of medicine’s top mythbusters. “People are being hurt and even dying” because of false medical claims, he says: not quackery, but errors in medical research.

对于医生、政策制定者以及重视健康的消费者来说,这是个令人不安而且意味深长的观点。最重要的支持者之一,约翰·P·A·埃尼迪斯,正把多年来对毫无根据的健康和医学主张进行讨伐的行动提升到一个全新的高度。作为斯坦福大学的预防医学研究中心的新长官,勒尼迪斯把自己的角色定位为医学方面的顶级流言终结者。因为错误的医学主张,“人们被伤害甚至导致死亡”他说:不是庸医,而是医学研究中的错误。

This is Ioannidis’s moment. As medical costs hamper the economy and impede deficit-reduction efforts, policymakers and businesses are desperate to cut them without lowering sacrificing sick people. One no-brainer solution is to use and pay for only treatments that work. But if Ioannidis is right, most biomedical studies are wrong.

这是一个埃尼迪斯时刻。因为医疗费用妨碍了经济并阻碍了降低赤字的努力。政策制定者和商业团体极度渴望削减医疗费用的同时减少病人患者的损失。一个显而易见的解决方法是只对治疗工作进行支付。但如果埃尼迪斯是对的,多数的生物医学研究都是错的。

In just the last two months, two pillars of preventive medicine fell. A major study concluded there’s no good evidence that statins (drugs like Lipitor and Crestor) help people with no history of heart disease. The study, by the Cochrane Collaboration, a global consortium of biomedical experts, was based on an evaluation of 14 individual trials with 34,272 patients. Cost of statins: more than $20 billion per year, of which half may be unnecessary. (Pfizer, which makes Lipitor, responds in part that “managing cardiovascular disease risk factors is complicated”). In November a panel of the Institute of Medicine concluded that having a blood test for vitamin D is pointless: almost everyone has enough D for bone health (20 nanograms per milliliter) without taking supplements or calcium pills. Cost of vitamin D: $425 million per year.

仅在最近的两周中,预防医学有两个台柱子不幸倒掉了。一个主要的研究包括没有很好的证据表明抑制素(类似立普妥或可定的药物)能够对无心脏病史的人有所帮助。由科克伦协作组织(一个全球性质的生物医学专家财团)主持的一项研究涵盖了14个独立研究项目和34272名患者。该研究表明抑制素的费用,每年高达两百亿美元,而其中有一半是毫无用处的。(制造立普妥的辉瑞公司做出了部分回应道:控制心血管疾病的各项因素是非常复杂的。)十一月份,一个医学研究小组得到结论:进行维他命D的血液测试是没有意义的:不需要补充钙片,因为几乎每个人都有足够的维他命D以保持骨骼健康(每毫升20纳克)。而每年维他命D的费用是:四亿两千五百万美元。

Ioannidis, 45, didn’t set out to slay medical myths. A child prodigy (he was calculating decimals at age 3 and wrote a book of poetry at 8), he graduated first in his class from the University of Athens Medical School, did a residency at Harvard, oversaw AIDS clinical trials at the National Institutes of Health in the mid-1990s, and chaired the department of epidemiology at Greece’s University of Ioannina School of Medicine. But at NIH Ioannidis had an epiphany. “Positive” drug trials, which find that a treatment is effective, and “negative” trials, in which a drug fails, take the same amount of time to conduct. “But negative trials took an extra two to four years to be published,” he noticed. “Negative results sit in a file drawer, or the trial keeps going in hopes the results turn positive.” With billions of dollars on the line, companies are loath to declare a new drug ineffective. As a result of the lag in publishing negative studies, patients receive a treatment that is actually ineffective. That made Ioannidis wonder, how many biomedical studies are wrong?

埃尼迪斯,45岁,并没有打算消灭医学神话。曾是一个神童(3岁时会进行小数计算,并在8岁写了一本诗集),在雅典医科大学他率先从所在的班级毕业,然后在哈佛大学完成了住院医生实习,90年代中期他在国家卫生研究所做艾滋病的临床诊断,后来在希腊约阿尼纳大学医学院主持流行病系。在国家卫生研究所期间他有了一个灵感,治疗有效地“正面的”药物诊断和治疗无效的“负面的”药物诊断使用了相同的时间。“但负面诊断用了额外的两年或四年时间才被披露,”他提醒道,“负面的诊断躺在文件柜里,或者这些负面的诊断被寄希望转为正面的而被继续进行。”数以亿计的美元源源不断的花掉,然后制药公司才不情愿的宣布某种药物无效。作为宣布负面诊断的最后结果,患者被迫接受治疗无效的现实。这使埃尼迪斯产生疑问,到底有多少生物医学研究是错误的?

His answer, in a 2005 paper: “the majority.” From clinical trials of new drugs to cutting-edge genetics, biomedical research is riddled with incorrect findings, he argued. Ioannidis deployed an abstruse mathematical argument to prove this, which some critics have questioned. “I do agree that many claims are far more tenuous than is generally appreciated, but to ‘prove’ that most are false, in all areas of medicine, one needs a different statistical model and more empirical evidence that Ioannidis uses,” says biostatistician Steven Goodman of Johns Hopkins, who worries that the most-research-is-wrong claim “could promote an unhealthy skepticism about medical research, which is being used to fuel anti-science fervor.”

他的回答写在2005年的一篇题目为“多数”的论文中,其论点是从新药的临床实验到前沿的遗传学研究,生物医学研究中充满了错误发现。埃尼迪斯对某些批评家提出的问题进行了深奥而精确地论证。“除了可以“证明”它是错误的之外,我确信很多主张确实跟常识相比都非常脆弱,经不起推敲,在所有的医学领域中,需要埃尼迪斯所采用的不同的统计模型和更具实验性的证据,”生物统计学家斯蒂夫·古德曼和约翰斯·霍普金斯说。他们担心“多数研究都是错的”的主张“会对医学研究产生不健康的怀疑论,并为反科学热推波助澜。”

Even a cursory glance at medical journals shows that once heralded studies keep falling by the wayside. Two 1993 studies concluded that vitamin E prevents cardiovascular disease; that claim was overturned by more rigorous experiments, in 1996 and 2000. A 1996 study concluding that estrogen therapy reduces older women’s risk of Alzheimer’s was overturned in 2004. Numerous studies concluding that popular antidepressants work by altering brain chemistry have now been contradicted (the drugs help with mild and moderate depression, when they work at all, through a placebo effect), as has research claiming that early cancer detection (through, say, PSA tests) invariably saves lives. The list goes on.

即使粗略的浏览一下医学期刊也会发现很多前卫的研究都一个个的倒在路边。1993年的两个研究结论认为维他命E可以预防心血管疾病,该结论在1996年和2000年被更严谨的实验所推翻。1996年的一个研究结论说雌性激素疗法可以减少老年痴呆症的风险也在2004年被颠覆。很多研究得到的关于流行的抗抑郁药物通过改变脑化学起作用的结论也被否定(药物缓和抑郁,如果起作用,是因为安慰剂效果),以及研究主张早期癌症诊断(PSA测试)总能够挽救生命等等,失败案例不胜枚举。

Despite the explosive nature of his charges, Ioannidis has collaborated with some 1,500 other scientists, and Stanford, epitome of the establishment, hired him in August to run the preventive-medicine center. “The core of medicine is getting evidence that guides decision making for patients and doctors,” says Ralph Horwitz, chairman of the department of medicine at Stanford. “John has been the foremost innovative thinker about biomedical evidence, so he was a natural for us.”

尽管埃尼迪斯的指责充满了火药味,但他已经和1500名科学家展开了合作,而且,斯坦福大学和他的缩影(预防医学研究中心),在八月份雇佣他掌管整个预防医学中心。“医学的本质是为患者和医生提供证据,”斯坦福医学系主任拉尔夫·霍维兹说,“约翰(埃尼迪斯)是生物医学的革新思想者,所以他天生就是我们所需要的人物。”

Ioannidis’s first targets were shoddy statistics used in early genome studies. Scientists would test one or a few genes at a time for links to virtually every disease they could think of. That just about ensured they would get “hits” by chance alone. When he began marching through the genetics literature, it was like Sherman laying waste to Georgia: most of these candidate genes could not be verified. The claim that variants of the vitamin D–receptor gene explain three quarters of the risk of osteoporosis? Wrong, he and colleagues proved in 2006: the variants have no effect on osteoporosis. That scores of genes identified by the National Human Genome Research Institute can be used to predict cardiovascular disease? No (2009). That six gene variants raise the risk of Parkinson’s disease? No (2010). Yet claims that gene X raises the risk of disease Y contaminate the scientific literature, affecting personal health decisions and sustaining the personal genome-testing industry.

埃尼迪斯的第一个目标是运用于早期基因研究中的伪劣的统计学方法。科学家会一次测试一个或几个基因并和他们所能想到的所有疾病联系起来。这正好可以确保使他们可以独自偶然的“中奖”,当他开始进行基因学领域研究的竞赛时,就像谢尔曼糟蹋格鲁吉亚一样,多数候选基因都没有被验证。研究表明维他命D受体的变异可以解释四分之三的骨质宿松症?错啦,他和同事们在2006年证明了,该变异对骨质酥松没有影响。被国家人类基因组研究中心鉴定的大量基因可以用于预测心血管疾病?也错啦(2009)。6个提高帕金森氏症风险的基因?还是错的(2010)。主张基因X提高了Y疾病的风险的理论不但玷污了科学文献,还影响了个人健康决策并支持了个人基因测试工业。

Statistical flukes also plague epidemiology, in which researchers look for links between health and the environment, including how people behave and what they eat. A study might ask whether coffee raises the risk of joint pain, or headaches, or gallbladder disease, or hundreds of other ills. “When you do thousands of tests, statistics says you’ll have some false winners,” says Ioannidis. Drug companies make a mint on such dicey statistics. By testing an approved drug for other uses, they get hits by chance, “and doctors use that as the basis to prescribe the drug for this new use. I think that’s wrong.” Even when a claim is disproved, it hangs around like a deadbeat renter you can’t evict. Years after the claim that vitamin E prevents heart disease had been overturned, half the scientific papers mentioning it cast it as true, Ioannidis found in 2007.

统计学上侥幸行为也殃及了流行病学,在研究者寻找健康和环境之间的联系,包括人们的行为和饮食方面。一个研究可能试图回答咖啡是否提高了关节痛、头痛、胆囊疾病或者其他疾病的风险。“当你做了数千次的测试之后,统计学却告诉你一个错误的结果。”埃尼迪斯说。制药厂正是依靠这些不确定的统计获得了巨额利润,他们通过测试一种已核准的药物的其他用途来撞大运。“而且医生基于那个(不确切的统计)来开处方使药物产生新的用途。我认为这是错误的。”即使一个结论被证明是错的,但它就是像是一个落魄的承租人一样让你没办法彻底驱逐他。埃尼迪斯发现,在维他命E与心脏病的结论被推翻的数年之后,还有一半的科学论文将其当做正确的加以引用。

The situation isn’t hopeless. Geneticists have mostly mended their ways, tightening statistical criteria, but other fields still need to clean house, Ioannidis says. Surgical practices, for instance, have not been tested to nearly the extent that medications have. “I wouldn’t be surprised if a large proportion of surgical practice is based on thin air, and [claims for effectiveness] would evaporate if we studied them closely,” Ioannidis says. That would also save billions of dollars. George Lundberg, former editor of The Journal of the American Medical Association, estimates that strictly applying criteria like Ioannidis pushes would save $700 billion to $1 trillion a year in U.S. health-care spending.

形势并非完全绝望。大部分的基因学者已经修正了他们的方向,提高了统计标准,但在其他领域仍然需要清理门户,埃尼迪斯说。例如,外科手术实施的必要性几乎没有被验证。他说:“我不会感到惊讶,一大部分的外科手术是建立在子虚乌有之上的,如果我们仔细研究,他们就会消失。”那同样可以节省数十亿美元。美国医疗协会杂志前编辑乔治·伦德伯格估计如果严格的实施埃尼迪斯推行的标准,美国每年可以节约七千亿到一万亿的卫生保健费用。

Of course, not all conventional health wisdom is wrong. Smoking kills, being morbidly obese or severely underweight makes you more likely to die before your time, processed meat raises the risk of some cancers, and controlling blood pressure reduces the risk of stroke. The upshot for consumers: medical wisdom that has stood the test of time—and large, randomized, controlled trials—is more likely to be right than the latest news flash about a single food or drug.

当然,并非所有的传统健康智慧都是错误的。吸烟死亡、病态肥胖或体重严重不足都会使人早死,经过处理的肉提高了一些癌症的风险,而且控制血压会减少中风的危险。提醒消费者:医学智慧需要经得起时间的检验,并被大量的、随机的、受控的病例所证明其正确性,这比某个药物或食品的最新消息更加重要。

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