Remember that antimalarial treatment US President Trump said should be "put in use immediately" against Covid-19 back in March? He took a lot of flak for backing hydroxychloroquine, but now a new study of almost 3,500 patients in Italian hospitals has found it cuts death rates by 30 per cent.
Not so fast: in the past few days another study, this time involving about 12,000 patients given the drug, known colloquially as HCQ, concluded it does not save lives at all – and may actually be harmful. So who is right?
Welcome to the baffling world of evidence-based medicine, where science seems incapable of reaching definitive answers.
Hardly a week goes by without some equally headline-grabbing study turns accepted wisdom on its head
It is not only with Covid-19 that the evidence seems to forever flip-flop. In recent weeks, researchers have claimed that statins may really be useless for controlling cholesterol, and that pregnant women face a far higher risk from caffeine than currently believed.
Hardly a week goes by without some equally headline-grabbing study turning accepted wisdom on its head. Yet while they often appear in prestigious journals after supposedly being checked by experts, the truth is they are not equally reliable. This is not because the researchers are making stuff up (though that can and has happened).
Most often, the reason is the study or the interpretation of its findings – and sometimes both – is not fit for purpose.
Again, this does not (necessarily) mean the researchers are incompetent. So what are the telltale signs a study is likely to prove reliable?
What is the most reliable type of study?
When investigating “what works”, the gold standard is a double-blinded Randomised Controlled Trial, or RCT. Put simply, these compare two groups of patients, randomly allocated to receive either the treatment under test, or an alternative “control” treatment, which is often an inactive placebo.
The randomisation cuts the chances of anything other than the treatment affecting the outcome, as both groups are equally likely to get their share of patients who fare better or worse from other causes.
Both the researchers and the patient are also “blinded” to who is getting what, to eliminate any bias – unconscious or deliberate – in interpreting the outcome.
So why aren’t RCTs always used?
Decades of research have shown that most treatments do not work with most patients. As a result, an RCT will often need many hundreds or even thousands of patients to reveal the effectiveness of a treatment with enough precision to tell if it’s worth using. This makes RCTs time-consuming and very expensive – and often limits their size.
An alternative is to run a so-called observational study, where researchers just compare those given the treatment with those who weren’t – while trying to account for any effects not caused by the treatment by analysing patient data. This was the approach used by researchers in Italy who claimed HCQ is effective against Covid-19.
What is wrong with observational studies?
Lacking randomisation and blinding, observational studies can fall prey to various biases, including unknown “confounders” that aren’t balanced out between the two groups of patients.
The Italian study on HCQ was also retrospective, meaning the researchers could not always find important information such as what dosage patients received, or whether other drugs were also used. So while the sheer number of patients looks impressive, the study’s headline claim was treated with scepticism by many researchers.
How about combining lots of small trials?
While the most reliable evidence comes from large RCTs, it’s possible to combine many small studies in a “meta-analysis”. This is what an international team has now done for HCQ, examining 28 studies of patients who received the drug.
As most of the studies were observational, the team carried out a “systematic review” to weed out studies at high risk of bias. They then used statistical methods to combine the outcome of those remaining, including three RCTs. The results – based on more than 12,000 HCQ patients – were revealing.
The observational studies collectively pointed to a possible benefit from HCQ, but with a lot of uncertainty. In contrast, the three RCTs all pointed to HCQ being at best useless – and most probably harmful.
Given the greater reliability of RCTs, most researchers – and the World Health Organisation – have concluded HCQ should be abandoned.
So what about statins and cholesterol?
More than 200 million people worldwide take statins to protect against heart attacks and strokes. So last month's publication of a study claiming statins do not work inevitably made headlines.
On the face of it, the evidence seems impressive. The researchers based their conclusion on a systematic review of 35 studies – all of them RCTs – involving tens of thousands of patients.
However, the researchers didn't perform a meta-analysis, claiming the RCTs covered too many different types of patient and statin. Instead, they simply totted up how many of the RCTs gave statistically non-significant findings.
Crucially, this does not mean the trials had shown statins do not work – but merely that they have failed to give convincing evidence either way. Statisticians have warned researchers about making this blunder for decades.
Combined with other, more technical, errors, the statins study serves chiefly to show that publication in a “serious” journal is no guarantee of reliability.
What about caffeine and pregnant mums?
Mothers-to-be have long been advised to cut back on caffeine intake, but according to a new review of the evidence, the only safe amount is zero.
Again, the evidence seems impressive, being based on dozens of studies. Yet all but one were observational and thus subject to biases, making it impossible to claim caffeine is responsible for any ill-effects.
Importantly, the review was also not systematic – meaning the author may have missed studies that could overturn the overall conclusion.
The upshot for pregnant mums: nothing to see here – and don’t worry about having an occasional cup of coffee.
Robert Matthews is visiting professor of science at Aston University, Birmingham, UK
Some of Darwish's last words
"They see their tomorrows slipping out of their reach. And though it seems to them that everything outside this reality is heaven, yet they do not want to go to that heaven. They stay, because they are afflicted with hope." - Mahmoud Darwish, to attendees of the Palestine Festival of Literature, 2008
His life in brief: Born in a village near Galilee, he lived in exile for most of his life and started writing poetry after high school. He was arrested several times by Israel for what were deemed to be inciteful poems. Most of his work focused on the love and yearning for his homeland, and he was regarded the Palestinian poet of resistance. Over the course of his life, he published more than 30 poetry collections and books of prose, with his work translated into more than 20 languages. Many of his poems were set to music by Arab composers, most significantly Marcel Khalife. Darwish died on August 9, 2008 after undergoing heart surgery in the United States. He was later buried in Ramallah where a shrine was erected in his honour.
THE SPECS
Jaguar F-Pace SVR
Engine: 5-litre supercharged V8
Transmission: 8-speed automatic
Power: 542bhp
Torque: 680Nm
Price: Dh465,071
Why seagrass matters
- Carbon sink: Seagrass sequesters carbon up to 35X faster than tropical rainforests
- Marine nursery: Crucial habitat for juvenile fish, crustations, and invertebrates
- Biodiversity: Support species like sea turtles, dugongs, and seabirds
- Coastal protection: Reduce erosion and improve water quality
Other workplace saving schemes
- The UAE government announced a retirement savings plan for private and free zone sector employees in 2023.
- Dubai’s savings retirement scheme for foreign employees working in the emirate’s government and public sector came into effect in 2022.
- National Bonds unveiled a Golden Pension Scheme in 2022 to help private-sector foreign employees with their financial planning.
- In April 2021, Hayah Insurance unveiled a workplace savings plan to help UAE employees save for their retirement.
- Lunate, an Abu Dhabi-based investment manager, has launched a fund that will allow UAE private companies to offer employees investment returns on end-of-service benefits.
COMPANY%20PROFILE
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Moral education needed in a 'rapidly changing world'
Moral education lessons for young people is needed in a rapidly changing world, the head of the programme said.
Alanood Al Kaabi, head of programmes at the Education Affairs Office of the Crown Price Court - Abu Dhabi, said: "The Crown Price Court is fully behind this initiative and have already seen the curriculum succeed in empowering young people and providing them with the necessary tools to succeed in building the future of the nation at all levels.
"Moral education touches on every aspect and subject that children engage in.
"It is not just limited to science or maths but it is involved in all subjects and it is helping children to adapt to integral moral practises.
"The moral education programme has been designed to develop children holistically in a world being rapidly transformed by technology and globalisation."
The biog
Name: Mohammed Imtiaz
From: Gujranwala, Pakistan
Arrived in the UAE: 1976
Favourite clothes to make: Suit
Cost of a hand-made suit: From Dh550
UAE currency: the story behind the money in your pockets
Know your Camel lingo
The bairaq is a competition for the best herd of 50 camels, named for the banner its winner takes home
Namoos - a word of congratulations reserved for falconry competitions, camel races and camel pageants. It best translates as 'the pride of victory' - and for competitors, it is priceless
Asayel camels - sleek, short-haired hound-like racers
Majahim - chocolate-brown camels that can grow to weigh two tonnes. They were only valued for milk until camel pageantry took off in the 1990s
Millions Street - the thoroughfare where camels are led and where white 4x4s throng throughout the festival
Lexus LX700h specs
Engine: 3.4-litre twin-turbo V6 plus supplementary electric motor
Power: 464hp at 5,200rpm
Torque: 790Nm from 2,000-3,600rpm
Transmission: 10-speed auto
Fuel consumption: 11.7L/100km
On sale: Now
Price: From Dh590,000
BRAZIL%20SQUAD
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Zayed Sustainability Prize
if you go
The flights
Etihad and Emirates fly direct from the UAE to Seoul from Dh3,775 return, including taxes
The package
Ski Safari offers a seven-night ski package to Korea, including five nights at the Dragon Valley Hotel in Yongpyong and two nights at Seoul CenterMark hotel, from £720 (Dh3,488) per person, including transfers, based on two travelling in January
The info
Visit www.gokorea.co.uk
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Tightening the screw on rogue recruiters
The UAE overhauled the procedure to recruit housemaids and domestic workers with a law in 2017 to protect low-income labour from being exploited.
Only recruitment companies authorised by the government are permitted as part of Tadbeer, a network of labour ministry-regulated centres.
A contract must be drawn up for domestic workers, the wages and job offer clearly stating the nature of work.
The contract stating the wages, work entailed and accommodation must be sent to the employee in their home country before they depart for the UAE.
The contract will be signed by the employer and employee when the domestic worker arrives in the UAE.
Only recruitment agencies registered with the ministry can undertake recruitment and employment applications for domestic workers.
Penalties for illegal recruitment in the UAE include fines of up to Dh100,000 and imprisonment
But agents not authorised by the government sidestep the law by illegally getting women into the country on visit visas.
The biog
Favourite colour: Brown
Favourite Movie: Resident Evil
Hobbies: Painting, Cooking, Imitating Voices
Favourite food: Pizza
Trivia: Was the voice of three characters in the Emirati animation, Shaabiyat Al Cartoon
Other must-tries
Tomato and walnut salad
A lesson in simple, seasonal eating. Wedges of tomato, chunks of cucumber, thinly sliced red onion, coriander or parsley leaves, and perhaps some fresh dill are drizzled with a crushed walnut and garlic dressing. Do consider yourself warned: if you eat this salad in Georgia during the summer months, the tomatoes will be so ripe and flavourful that every tomato you eat from that day forth will taste lacklustre in comparison.
Badrijani nigvzit
A delicious vegetarian snack or starter. It consists of thinly sliced, fried then cooled aubergine smothered with a thick and creamy walnut sauce and folded or rolled. Take note, even though it seems like you should be able to pick these morsels up with your hands, they’re not as durable as they look. A knife and fork is the way to go.
Pkhali
This healthy little dish (a nice antidote to the khachapuri) is usually made with steamed then chopped cabbage, spinach, beetroot or green beans, combined with walnuts, garlic and herbs to make a vegetable pâté or paste. The mix is then often formed into rounds, chilled in the fridge and topped with pomegranate seeds before being served.
It Was Just an Accident
Director: Jafar Panahi
Stars: Vahid Mobasseri, Mariam Afshari, Ebrahim Azizi, Hadis Pakbaten, Majid Panahi, Mohamad Ali Elyasmehr
Rating: 4/5
