👋 Happy Friday. Sorry for the short hiatus. I would never leave you, I promise. I just had to run out and get some milk. But it’s okay now. Daddy’s home. How can I make it up to you? With medical news you say? I’ll gladly oblige.

Here’s what we got:

• 🧐 The Ticagrelor Files Declassified: BMJ Expose It’s Murky Past

• 🙊 A Study That Gives The Name 'Ward Monkey' Some Credibility

• #TheMoreYouKnow: Other Top Stories of The Week

RESEARCH NEWS

🧐The Ticagrelor Files Declassified: BMJ Expose It’s Murky Past

Now this is interesting. The BMJ have published a massive exposé on everyone’s third favourite anti-platelet drug, ticagrelor. I know it’s Love Island time. But I promise, this tale has more twists and turns than the Diddy trial. Here’s how the story goes:

The year is 2009. Swine flu is raging, global markets in freefall, and Astrazeneca has a new drug brewing. Aspirin’s already generic, and Plavix (aka clopidogrel) is about to lose its patent. Cue the dollar signs. AstraZeneca sees its moment.

So they dropped three ‘landmark’ studies, launching ticagrelor, the superior P2Y12 platelet inhibitor, to the world. PLATO, ONSET/OFFSET and RESPOND released in quick succession between August 2009 and March 2010. And it got these cardiologists more hot n’ bothered than teenage girls at a K-pop concert. They had some big claims:

• PLATO(NEJM 2009): This study claimed Ticagrelor reduced CVD death, MI’s and strokes more effectively than clopidogrel than ACS patients, with a 16% risk reduction across 18,000 patients.

• ONSET/OFFSET(Circulation 2009): This one said Ticagrelor provides faster and greater platelet inhibition than clopidogrel within 30 mins of administration. Looking ideal for emergencies like PCI 👀

• RESPOND(Circulation 2010): If there was any doubt on its superiority, This study claimed ticagrelor could achieve platelet inhibition in those who clopidogrel didn’t work on. 

This trifecta set the narrative. Ticagrelor led to faster, stronger, more reliable inhibition => better clinical outcomes. In 2011, it was FDA and NICE approved and entered the NHS that same year. Millions of patients were managed well. Astrazeneca is rich.

Everyones happy? Not the BMJ. They had a problem. It smelt something was fishy about each of these studies. Far too good to be true. 

The first whistleblowers came out in Jan 2010. FDA’s Dr Thomas Marchiniak’s had a look at the studies when Astrazeneca applied for approval and was confused? These clinical benefits supposedly shown in the PLATO study didn’t add up. If ticagrelor really worked faster and stronger, especially in emergencies like PCI, you'd expect those patients to do better, right? But Marciniak noticed the opposite. Patients treated early actually fared worse on ticagrelor than clopidogrel. This curious mishap spun up a whole web of controversy:

• Primary endpoint manipulation: RESPOND’s original result wasn’t statistically significant, but was published as so, without disclosure…

• Missing platelet data: Over 60 platelet activity readings never made it to the FDA dataset. These missing results showed weaker inhibition

• Suspicious study design: 6 blood draws per visit? For a study without pay? How did they recruit 123 patients to get jabbed 6 times for several weeks? Sound pretty unlikely…

• Ghost authors and missing investigators: When the BMJ asked for the opinions of several investigators, many of them wouldn’t talk or had no comment(I feel scaring writing this article at all)

• Phantom patients: Several subjects had data recorded without baseline platelet tests, meaning they were dropped from analysis, but the trial still called it intention-to-treat. Not quite how math(or ethics) works. 

So here we are. 15 years, Billions of dollars and millions of prescription and it comes out the data may be as flimsy as a stethoscope from Temu. Circulation, NEJM and AstraZeneca refuse to comment. 

This year ticagrelor goes generic. The profits are locked in and regulators have moved on. Vindication for BMJ is unlikely. But I'll still be giving AstraZeneca the side eye when their next “groundbreaking” drug comes through the system.

NHS NEWS/RESEARCH UPDATE

🙊 A Study That Gives The Name 'Ward Monkey' Some Credibility

Why did you sign up to become a doctor? 

Was it because you wanted to ‘help people’ or ‘save lives’. Such a noble and naïve 17 year olds we were. So cute. So dumb. (If you’re a GEM, I’m genuinely curious—what was your reasoning? Reply to this email. No, really.)

Amongst the reasons above, it was about being on your feet. An active, ever-changing job and not dying behind Powerpoint, Excel and shareholder value. Whilst we are free from the shackles of Microsoft’s business suite, we have shackles of our own…

Behind computers running Windows 2007, we have admin purgatory. There are few things as soul sucking as writing up notes on Epic, EMIS and Cerner. Documenting a ward round only to realise you forgot to hit ‘Save’ 💔. But how much of your day-to-day do you think you spend in admin hell?

This study, published in QJM, aimed to quantify how UK resident doctors allocate their time between patient-facing and non-patient-facing tasks(i.e. admin) and also check out this impacted job satisfaction. 

This national, multicentre, observational cohort study took 137 resident doctors(FY1 to ST8) in secondary and tertiary centres. They got medical students to follow them around with a stopwatch for 4-hours and note down what the doctors were doing:

• Patient-facing, doctor-specific (e.g., history taking, examinations)

• Patient-facing, non-doctor-specific (e.g., procedures)

• Non-patient-facing, doctor-specific (e.g., MDT discussions, prescribing)

• Non-patient-facing, non-doctor-specific (e.g., documentation, discharge summaries)

• Other (e.g., teaching, breaks)

And at the end of all of that, the medical students slid a job satisfaction survey across the table to see how they feel about it all. 

What did they find? Residents spent around 73% of their time on non-patient facing tasks and a measly 17.9% actually talking to patients. Now what would that 17 yr old self say about that? Additionally:

• Women spent more time on non-patient facing tasks than men(75.0% v 69.9%)

• Senior RD’s spent more time with patients than juniors (38.4% v 17.8% – no suprise)

• 63% of survey respondents reported dissatisfaction with administrative burden. These respondents also said the admin was a bigger problem than pay.

Granted, the study was far from perfect. Tiny sample size. Low survey response rate which could have led to overrepresentation of dissatisfied doctors. Also, what are the odds of a medic paying attention to a doctor for 4 hours straight? Very low. This could have led to problems with observer results.

So, what do we do with all this?

Honestly? Probably keep doing what we’re doing. Sighing, coping, maybe sending a passive-aggressive feedback form once a year. But at the very least, let’s stop pretending this is normal. When 73% of your job is admin, and the bit you actually trained for feels like a side hustle, something’s definitely gone wrong.

QUICK BITS: OTHER NEWS YOU SHOULD KNOW

• STRIKE-OFF OF THE WEEK: Work-Rota Infidelity: A Consultant is struck off for cheating on his contracted full-time NHS trust. The doctor fell victim to the seduction of the locum shift pay-uplift. It was so enticing he cheated 116 times(with 116 shifts) between 2019 and 2022. His sneaking around caught up to him with as he was struck-off. Harsh? Probably. MTPS said the decision would “deprive the public of another good doctor.

• Treatment-Resistant Depression Treated with Parkinsons Medication: It’s not just Ozempic that has benefits outside its intended use. Spare yourself the rods. No need for deep brain stimulation. The NHS trial for Pramipexole for depression work really well. Except from the side effects that led to 1/5 patients dropping out. But hey, if you have Parkinsons and Depression, it could be an effective way to avoid polypharmacy.

• Finally Getting With The Times. GP’s Getting New IT System For The First Time In 25 Years: What a timely topic. Medicus Health promises to take GP’s out of the dark ages and into the present with a new cloud-based EHR. Everyone seems to like it in the test sites. Soon to be distributed with ICB’s around the country.

• HIV Care Takes an Inspiration From Robin Hood: A brand new twice-yearly PREP injection promised to take the HIV world by storm. No need to worry about continous or event based pills. 2 injections a year is all thats need. Tiny little catch. It costs $25,000 💀. That’s alright because the company producing them says it will make it cheap for third-world countries that need it the most. Just $25. Robin Hood or fake altruism? Thats for you to decide.

• The NHS 10 Year Plan Is Out: Is It Really Fit For The Future?: Not sure yet. It’s a rather large document, well over 140 pages. The team will have fun digesting it over the next couple days for quality summary. You can read it in the link below if you so fancy.

Handover Over 🫡 

If you liked it, tell your mates.
If you hated it, tell your enemies.

Look. I know I just came back with the milk, but I just realised I forgot the bog roll. We may or may not be back on Sunday with a Deep Dive. What’s it about? You’ll have to wait and see 👀 

For those of you new here. Welcome to The Handover! So glad to have you on board. Let me know what you thought in the poll below 👇️ 

For those who have been here a while. We are thinking of shaking things up. This week we had more detail in the Quick bits but fewer full length stories. Which did you prefer?

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