Thread by @ProfDFrancis

Happy Easter Sunday!

Today's tweetorial is short and nasty, like me.

#FOAMED #MEDED #Cardiotwitter

Last night I broke into a pharmacy to steal some drugs.

After crowbar'ing my way in, I was in an Alladin's cave of stuff.

With my full-face Covid Scarf (© Donald Trump), I couldn't read the names of the medications.

So I just loaded up my backpack full of any medications I could lay my hands on, and ran for it.

Yes, all available from Francis Industries.

At home I spread out the loot.

NICE!

I choose one agent (in my case, I liked the look and taste of the little yellow ones, and so went for them).

And I take it regularly.

And millions of my loyal followers on Twatter also do their own break-ins, grab a medication at random, and take that one regularly.

Each of 1 million devoted Francisites chooses a medication at random, and takes it consistently from then on, for ever.

Roughly how many of the 1 million of us will get net health benefits from their randomly-chosen agent from the pharmacy?

And how many of the million will have no particular net health effects? (e.g. they were lucky to pick homeopathic crap or water soluble vitamins etc)

By the way I forgot to say that this whole break-in was the idea of Vinay Prasad.

(Only he made a more intelligent version of this tweetorial with graphs etc: I have just simplified it)

How many picked an agent that doesn't do anything much, either way?

And how many of my million unquestioning, fanatic Francisites have stumbled upon something like one of these:

This is the UK BNF, equivalent to the Physician's Desk Reference in USA.

Here are some headings for drugs. I've randomly scrolled to "D".

Here is another random letter, "M".

I've highlighted in Yellow the section of drugs where taking one regularly, when you don't need it, will likely do you harm.

I haven't bothered to open up any of the sections: as a doctor you know very well what is in there.

Stuff you wouldn't want streamed daily into members of your family who didn't need it.

Just because some idiot on twitter says so.

And I have been stingy with my highlighting. Only things which are barn-door obviously bad stuff.

I missed "mydriatics and cycloplegics", for example, as they sounded innoccuous at first, but on reflection it is net harm to most and especially if they are driving!

So, of my million followers, how many will be harmed by going onto a randomly chosen medication?

Now let's review.

Of the million, the number of people that hit the jackpot, e.g. picked up a penicillin when they happened to be about to have meningococcal meningitis, is likely under 1,000 as you correctly identified.

And the number that get a net-neutral drug is probably somewhere in the range 200,000 to 800,000. Your guess is as good as mine.

So ...

... based on the figures above (let's be ultra generous and take 800,000 neutral and 1,000 beneficial), how many of my million devoted Francisites will be *harmed* by their randomly chosen regime?

Next year's Francis Fan Club?

"We're gonna need a smaller convention centre"

"Random can be good or bad.

Taking random shit from a pharmacy is bad.
Randomizing in a trial is good."

Albert Einstein
J Pharmacol Obv, 2020

If, instead of saying "just pick a drug and take it", I said "just pick a drug and take EITHER it OR placebo", there would be several consequences.

First, instead of (say) 199,000 people dying, how many will die?

Pick the closest to the correct answer.

And another benefit is that people will publish papers saying

"Oh look, amongst the people who grabbed Insulin actrapid 100U, the people who were randomized to the placebo arm seemed to mysteriously die a lot less than the active arm. Could there be a causal link?"

As well as a whole lot of

"Hmmm... ten thousand people took Francis Industries' Hair Tonic, and in them there was no difference between the active and placebo.

This is obviously a rubbish way of preventing corona."

And so with relatively few deaths, we will be able to find out that most of the pharmacy is a load of crap, for preventing deaths from Corona.

So that, dear readers, is why UNTIL we have a convincing RCT (i.e. not containing obvious fictionalisations) we should enrol in RCTs, rather than listening to morons on the internet who say their random thing is really good.

Competition for the day
---------------------------

Can people find anyone who has said the Hydrochloroquine trial paper was reason to just give it to people?

Paste links and we can mock them.

Likewise the "remde tr" (half way to being a remdesivir trial, just lacking the control arm) that popped up in NEJM for no particular reason.

Anyone who was convinced by that, please paste links so we can mock

And definitely anyone who tries to push "compassionate use" of random bollocks.

EVERYTHING in that pharmacy I robbed has decades of safety data and is used by millions daily.

Choosing a thing at random from it, however, is far, far more likely to kill you than save your life.

Reply to this tweet with links to moronicness so we can join in the mockumentation.

Thanks Jason! Sorry I got a bit steamed up but it is quite annoying that people can't tell nonsense when they see it.

You are right.

There is no danger to people from telling them "go take a random tablet from pharmacy". Even stupid people recognise that as insane.

The danger comes from saying "go take X because of Y". A great many people have no ability to understand whether Y makes any sense or not.

... which contains the following ...

And of course we must not leave out ...

The problem is even worse for doctors.

We are taught to explain everything convicingly.

I can very easily convince an audience that flecainide is a great thing to give people with ectopy post MI, but that we must of course limit it to those who ectopy goes away on it, and comes back on stopping.

Sounds good!

But it kills you.

Routine oxygen for MI

Eschewing beta blockers in heart failure

Bed rest for MI

Cardiac Resynchronization Therapy for Narrow QRS Heart Failure with Mechanical Dyssynchrony

Of course I am being harsh.

Some of the people picking random drugs will accidentally pick up an antihypertensive or a statin, and be someone who could get benefit from it.

And naturally someone picking up Garlic extract, will of course get protection:

I hesitated for a day before adding this next one to this thread, because of the fear that people might actually do it.

However, technically it does definitely work. If the patient dies and gets cremated, 100% of the virus particles in the patient are indeed killed.

So, in the words of the Leader of the Freak World, "What have you got to lose?"