what the research says

Monday, June 2, 2014

While California Chrome prepares for the Belmont Stakes and a run at the Triple Crown, there may already be a winner crossing the finish line in the advertising derby. Who knew that the nasal strips that are marketed to help control snoring in people were also being marketed to help horses run faster. Flair equine nasal strips made news when CC had to get permission from the New York racing authority to wear them in the upcoming race. No such permission was required at the Kentucky Derby or the Preakness. Those who make the decisions allowed the strips because there was no evidence that they improved performance and therefore felt they were a non-issue. The makers of the strips disagreed, touting their performance enhancement benefits, plus the owners of the horse believe that they work. But why should we care? It’s all about science, research and spinning the data to make a point.

In people medicine, the introduction of new medication or a new technique requires experiments to be done to decide whether the new is better than the old. And sometimes, research is needed to prove that the old wasn’t as good as we thought it was. Much of what medicine presumes to know as dogma, may actually be wrong and potentially harmful. For generations, certain medications were thought to be lifesaving when it came to resuscitating the heart, but the data to prove their worth was lacking. When re-examined, it changed the protocols that the American Heart Association had taught for decades. Some treatments have a fad like status, lasting only a few years while they are tweaked and refined. Whether it is the depth of cooling of patients resuscitated from sudden death, to how much fluid to give to a trauma patient who is bleeding, or how quickly to breathe for a patient who is in coma from a head injury, the standard care pathways are in constant flux depending upon the latest research.

So back to California Chrome. It seems that horses can be research subjects just like humans with experiments set up to learn about physiology and disease and veterinary labs are ready and willing to put horses on treadmills and study their heart, lung and muscle function. When horses run, their hearts generate significant cardiac output, meaning that lots of blood can be pumped through the lungs to pick up oxygen to be delivered to their muscles. This pressure within the lung tissue can damage the tiniest of blood vessels, the capillaries, and cause them to leak blood. Exercise induced pulmonary hemorrhage occurs in most racehorses during high intensity running. Blood leaking into the lung requires the horse to rest longer between races and training, it negatively affects performance and on occasion causes death. Furosemide is a common drug used to prevent or minimize the bleeding but the drug is sometimes used as a masking agent to hide performance enhancing drugs in horses (and in humans).

It’s tough to study exercising horses but researchers found a way. They compared the amount of bleeding (a tube has to be placed into the trachea and the lungs washed out to see how much blood can be collected) in a racehorse during exercise with no treatment as a control, with the nasal strips and with furosemide. In some studies, the nasal strips helped decrease bleeding but furosemide was more than twice as effective. In other studies, the nasal strips were not found to be effective. And in some studies, the nasal strips improved performance negligibly and in others there was not improvement at all.

Imagine a human study where the benefit of a drug or a procedure was too small to measure. Would people be willing to ask for such a treatment? The answer is not always rational but depends upon the situation. Parents often bring their infant to the hospital or clinic because of a fever and the worry about an ear infection. As it turns out, most are caused by viruses and but many health care providers still prescribed antibiotics, even though they are likely not useful in the first few days. The latest treatment strategy is to write the antibiotic prescription but ask the parents not to fill it for at least 48 hours, presuming that most viral infections will resolve in that time frame and the infant will get better with the tincture of time. But how many doctors are willing to have a long conversation with the parents and how many parents are willing to wait, when there is a medication that might work. The downside to prescribing too many antibiotics…bacteria develop resistance to commonly used antibiotics and infections in the future may be harder to treat.

Imagine cancer patients whose treatment options have come to an end and search for alternatives that have not been proven to work but yet may offer hope. From laetrile to macrobiotics to oxidative therapies, there are dozens of cancer treatments that beckon those who have failed conventional medical treatment. Science doesn’t matter when hope has been lost.

California Chrome may win at Belmont because he is faster and stronger, but not necessarily because of what he wears across his nose. But don’t tell that to his owner or the makers of the Flair equine nasal strips.

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