Category: Health

“Medicine Is Riddled With Flawed, Incomplete Evidence”

William Osler’s hospital residency system may have been an advance when he invented it. But it is far from perfect. We need lighter regulations so that medical entrepreneurs can create institutional innovations.

(p. D3) Medicine is full of young recruits writing veterans’ books, war stories full of hopes and fears for the next in line.

. . .

None in recent memory has wielded a set of intellectual and writerly tools to such dazzling and instructive effect as Dr. Nussbaum’s “The Finest Traditions of My Calling: One Physician’s Search for the Renewal of Medicine.”

. . .

. . .  Dr. Nussbaum steers his narrative directly to the hard questions about 21st-century medicine, a profession just about as variously troubled as his patients.

. . .  None of the usual medical heroes apply. Even the enduring William Osler, who started the hospital residency system at the turn of the 20th century and is routinely worshiped as a medical saint, comes up short. Osler was all about the physical evidence of illness, and Dr. Nussbaum faults him for seeing the body primarily as a collection of diseased parts, “a decidedly incomplete view.”

Few of Osler’s heirs strike Dr. Nussbaum as free of their own shortcomings.

He notes that partisans of today’s much promoted evidence-based medicine must determinedly finesse the fact that medicine is riddled with flawed, incomplete evidence. The leaders of genomic revolution trumpet a future that keeps being postponed. Quality-control gurus abound, but their work often fails to yield actual quality.

And those who would update and streamline medical routines offer up paradigms Dr. Nussbaum finds simply bizarre. He points to Atul Gawande, the Harvard surgeon and health policy writer who in a New Yorker article lauded the ability of large chain restaurants like the Cheesecake Factory to serve a uniform, reproducible product thousands of times over. Dr. Gawande charged medicine to do likewise, but that image of the physician as a line cook feeding faceless strangers does not inspire Dr. Nussbaum.

Still, if a doctor is to be neither parts mechanic nor line cook, then what? Dr. Nussbaum considers some alternatives.

. . .

Dr. Nussbaum considers the alternatives in a flowing, complex stream of anecdotes and reflections, all the stronger for its frequent uncertainty. He writes beautifully, in a lucid prose as notable for its process as its conclusions: The reader can actually watch him think.

For the full review see:

Abigail Zuger, M.D. “Unsparing Examination by a Young Doctor.” The New York Times (Tuesday, April 5, 2016 [sic]): D3.

(Note: ellipses added.)

(Note: the online version of the review has the date April 4, 2016 [sic], and has the title “Book Review: ‘The Finest Traditions of My Calling’.”)

The book under review is:

Nussbaum, Abraham M. The Finest Traditions of My Calling: One Physician’s Search for the Renewal of Medicine. New Haven, CT: Yale University Press, 2016.

Healthcare Competition Sometimes Reduces Prices

Numerous complex government healthcare regulations differentially increase the costs of small healthcare firms and independent healthcare practitioners that cannot afford to hire the specialized experts to understand and navigate the regulations. As a result the small firms and independent practitioners often give up and merge with larger organizations, thereby reducing competition. Also, in many locations, governments give incumbent hospitals veto power over the start-up of new hospitals, thereby also reducing competition.

(p. A3) Prices for surgery, intensive care and emergency-room visits rise after hospital mergers. The increases come out of your pay.

Hospitals have struck deals in recent years to form local and regional health systems that use their reach to bargain for higher prices from insurers. Employers have often passed the higher rates onto employees.

Such price increases added an average of $204 million to national health spending in the year after mergers of nearby hospitals, according to a study published Wednesday [April 24, 2024] by American Economic Review: Insights.

Workers cover much of the bill, said Zack Cooper, an associate professor of economics at Yale University who helped conduct the study. Employers cut into wages and trim jobs to offset rising insurance premiums, he said. “The harm from these mergers really falls squarely on Main Street,” Cooper said.

For the full story see:

Melanie Evans. “Hospital Prices Rise After Mergers, and Patients Bear Brunt.” The Wall Street Journal (Thursday, April 25, 2024): A3.

(Note: bracketed date added.)

(Note: the online version of the story was updated April 24, 2024, and has the title “The True Cost of Megamergers in Healthcare: Higher Prices.” The online version says that the title of the print version was “Hospital-Care Prices Rise After Mergers.” But my national edition of the print version had the title “Hospital Prices Rise After Mergers, and Patients Bear Brunt.”)

The forthcoming article co-authored by Cooper, and mentioned above, is:

Brot-Goldberg, Zarek, Zack Cooper, Stuart Craig, and Lev Klarnet. “Is There Too Little Antitrust Enforcement in the U.S. Hospital Sector?” American Economic Review: Insights (forthcoming).

Low Government-Negotiated Drug Prices Will Slash Pharma Revenue Needed to Finance Government-Mandated Costly Phase 3 Trials

Mandated Phase 3 randomized double-blind clinical trials cost many millions of dollars each, and most of the trials fail. To fund all the trials that fail and the few that succeed, the few new drugs that succeed need to have high price tags. The only other way for new drug development to be economically sustainable, is to stop mandating Phase 3 clinical trials. If we stopped mandating Phase 3 clinical trials, we would, in other words, allow physicians and patients to try drugs after safety has been shown through Phase 1 and Phase 2 trials, but without the expensive proof of efficacy from Phase 3 trials. We would thereby allow physicians and patients greater freedom.

(p. B6) While many companies, from Pfizer to Bristol-Myers Squibb to Bayer and Novartis, have announced big layoffs, news from a key outsourcer on Wednesday [Aug. 7, 2024] showed that the industry’s cost-cutting ways are intensifying.

Charles River Laboratories International, which provides drug-development services, plunged 12.6% on Wednesday [Aug. 7, 2024], the most in four years, after sounding the alarm over pharma research spending plans. The Massachusetts-based company said it now expects to post a decline in sales for the full year, primarily owing to lower demand from pharma clients. The company previously expected to grow this year. “There are profound cuts at pharmaceutical companies,” James Foster, Charles River’s chief executive officer, told analysts. Foster called the reduction in pharma research spending “unusual” and “sudden.”

Foster said his clients are blaming the cuts on the Inflation Reduction Act, which allows Medicare to negotiate some drug prices directly with manufacturers, and a looming patent cliff, which will see more than $200 billion in annual drug sales come under threat from copycat generics.

For the past few years, pharma companies have been warning that they might need to cut back on innovation as the U.S. government forces some companies to negotiate prices of their top-selling drugs.

. . .

A reduction in preclinical testing, the kind of services that Charles River provides, is the sort of thing that will only be felt in the long term. By that time, current management teams, desperate to lift their stocks now, might be long gone.  . . .

Big pharma wants to clean house. Expensive studies of drugs that won’t make it to market for many years to come are an easy target.

For the full commentary see:

David Wainer. “Big Pharma Scales Back R&D, Sending Shudders Through Industry.” The Wall Street Journal (Friday, Aug. 9, 2024): B6.

(Note: ellipses, and bracketed dates, added.)

(Note: the online version of the commentary has the date August 8, 2024, and has the title “Big Pharma Cuts R&D, Sending Shudders Through Industry.” The quoted paragraph starting with “Foster said” appears in the online, but not the print, version of the commentary.)

Mitochondria and Chloroplasts Arose Through the Horizontal Evolution of Endosymbiosis

(p. A13) Mr. Mindell, a senior researcher at UC Berkeley’s Museum of Vertebrate Zoology, offers an account of “horizontal” evolutionary processes that are not an alternative to the established view but a tweak and an addition.

. . .

The book . . . offers an updated, more sophisticated appreciation of how some living things, some of the time, exchange genes with members of the same generation.

. . .

Introgression—the mixing of genes between species—has been revealed in human ancestry by the presence, in modern populations, of Neanderthal and Denisovan DNA. Mr. Mindell points to other cases of introgression, including between coyotes and gray wolves and between brown and polar bears. “All hybridization phenomena, including introgression,” he writes, “qualify as horizontal evolution, because genetic material is exchanged between different species, rather than between parents and offspring, the path of vertical evolution. They denote networking rather than branching.”

. . .  . . . inter-species hybridization still has a vertical component. A notable exception is recombination, a process that is widespread in bacteria, archaea and certain viruses. Among these populations, individuals will occasionally connect, exchange genetic material and then go their separate ways: the equivalent of a one-night stand, with important consequences for human health. It is in part because of their penchant for such networking that the viruses that cause AIDS, influenza and Covid-19 are so quick to evolve and thus so difficult to combat.

As “The Network of Life” ably demonstrates, horizontal evolution has shaped ancient processes that have set the stage for life as we know it. Mr. Mindell pays special attention to endosymbiosis, in which one tiny organism comes to reside inside another, sometimes creating a merger. “Some of the most consequential innovations in life’s 3.8-billion-year history,” he writes, “stem from a joining of previously distinct lineages by endosymbiosis.” The process gave rise to mitochondria, the “energy powerhouses” of our cells, and to chloroplasts, the intracellular denizens that enable plants to conduct photosynthesis.

For the full review see:

David P. Barash. “BOOKSHELF; Natural Mixer.” The Wall Street Journal (Friday, June 28, 2024): A13.

(Note: ellipses added.)

(Note: the online version of the review has the date June 27, 2024, and has the title “BOOKSHELF; ‘The Network of Life’ Review: Natural Mixer.”)

The book under review is:

Mindell, David P. The Network of Life: A New View of Evolution. Princeton, NJ: Princeton University Press, 2024.

Black Physician Wants to “Play Fair” and Be Judged on Merit

(p. A17) Do I deserve to jump the line? If I say yes, I may play a leading role in ending the scourge of atherosclerosis—also known as hardening of the arteries. If I play fair, I may lose the opportunity to save people around the world from heart attacks and strokes. I’m angry at the National Institutes of Health for putting me in this position. I’m even angrier it has done so in the name of racial equity.

My quandary comes down to whether I should “check the box” on an upcoming NIH grant application attesting to my recent African heritage. Since at least 2015, the NIH has asserted its belief in the intrinsic superiority of racially diverse research teams, all but stating that such diversity influences funding decisions. My family’s origins qualify me under the federal definition of African-American. Yet I feel it’s immoral and narcissistic to use race to gain an advantage over other applicants. All that should matter is the merit of my application and the body of my work, which is generally accepted as foundational in atherosclerosis research.

. . .

If I refuse to identify myself as African-American, our application is more likely to lose on “diversity” grounds. It’s a double wrong. Not only is the system rigged based on nonscientific—and possibly illegal—criteria; it encourages me to join in the rigging.

Truth be told, I made my decision years ago. When my study team files our application, it won’t note my West African origins. If we don’t get the grant, so be it. I refuse to engage in a moral wrong in pursuit of a moral good—even one as important as saving lives from the leading killer on earth. My father, who struggled against racism to achieve so much on the merits of his own work, would never forgive me for “checking the box” to grab a race-based advantage.

And no matter what happens, I can never forgive the National Institutes of Health for reinjecting racism into medical research.

For the full commentary see:

Kevin Jon Williams. “Why I’m Saying No to NIH’s Racial Preferences.” The Wall Street Journal (Thursday, March 28, 2024): A17.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date March 27, 2024, and has the same title as the print version.)

Sweden’s Restraint in Mandating Covid Lockdowns Resulted in Much Lower Excess Mortality Than the U.S. Suffered

(p. A17) The best measure of health performance during the pandemic is all-cause excess mortality, which captures the overall number of deaths relative to the expected level, encompassing Covid and lockdown-related deaths. On this measure Sweden—which kept most schools open and avoided strict lockdown orders—outperformed nearly every country in the world.

A recent study published in the Proceedings of the National Academy of Sciences found that the U.S. “would have had 1.60 million fewer deaths if it had the performance of Sweden, 1.07 million fewer deaths if it had the performance of Finland, and 0.91 million fewer deaths if it had the performance of France.” In America, states that imposed prolonged lockdowns had no better health outcomes when measured by all-cause excess mortality than those that stayed open. While no quantifiable relationship between lockdown severity and a reduction in Covid health harms has been found, states with severe lockdowns suffered significantly worse economic outcomes.

. . .

The economic costs of lockdowns were also staggering. According to the Bureau of Labor Statistics, as many as 49 million Americans were out of work in May 2020. This shock had health consequences. A National Bureau of Economic Research study found that the lockdown unemployment shock is projected to result in 840,000 to 1.22 million excess deaths over the next 15 to 20 years, disproportionately killing women and minorities.

For the full commentary see:

Scott W. Atlas and Steve H. Hanke. “Covid Lessons Learned, Four Years Later.” The Wall Street Journal (Tuesday, March 19, 2024): A17.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date March 18, 2024, and has the same title as the print version.)

The “recent study” mentioned above is:

Ioannidis, John P. A., Francesco Zonta, and Michael Levitt. “Variability in Excess Deaths across Countries with Different Vulnerability During 2020–2023.” Proceedings of the National Academy of Sciences 120, no. 49 (Dec. 5, 2023): e2309557120.

The published version of the National Bureau of Economic Research study mentioned above is:

Bianchi, Francesco, Giada Bianchi, and Dongho Song. “The Long-Term Impact of the Covid-19 Unemployment Shock on Life Expectancy and Mortality Rates.” Journal of Economic Dynamics and Control 146 (Jan. 2023): 104581.

When Medical Insurers Own Doctor Practices, Medicare Advantage Creates “Conflicts of Interest and Opportunities to Game the System”

Through its Optum division health insurer UnitedHealth has 90,000 affiliated doctors. Under the federal government’s Medicare Advantage program, UnitedHealth received higher payments from the federal government for its customers who have more dire diagnoses. This creates an incentive for UnitedHealth to pressure its affiliated doctors to code their patients with dire diagnoses.

(p. A3) UnitedHealth has built a sprawling health services company that shows no sign of slowing down. With annual revenue of $372 billion in 2023, it ranks among the five largest companies in the U.S. on that measure. Its stock, meanwhile, has returned more than 600% in the past decade.

UnitedHealth’s success has been fueled by its expansion beyond insurance as its care delivery and solutions unit Optum steadily acquires a vast array of health services companies, from a pharmacy-benefits manager to specialty pharmacies to doctor groups and surgical centers. Over the past two decades, Optum has spent about $82 billion on nearly 100 acquisitions, according to a tally by Raymond James analysts.

Much like the rest of the U.S. economy, America’s healthcare system has consolidated in recent decades, creating giant hospital systems, chain-owned medical practices and vertically integrated insurance conglomerates. Immense scale can drive efficiencies and reduce the cost of care. But in the highly complex and opaque world of U.S. healthcare, where giant companies always seem to be a step ahead of regulators, it also raises potential conflicts of interest and opportunities to game the system. The benefits of size often flow to those companies, not patients or the employers and taxpayers footing much of the bill.

. . .

A key growth driver for UnitedHealth is Optum’s steady acquisitions of doctor practices. Optum now has ties with 90,000 doctors—about 10% of the country’s physician workforce.

. . .

Much of the vertical integration in the industry has focused on the Medicare Advantage business, the sector’s golden goose. These are the private plans in which the government pays insurers a fixed rate to manage the care of seniors. The sicker the patient, the more the government pays.

In recent years, some insurers’ acquisitions seem targeted at controlling the Medicare coding apparatus. If you control the doctors who code patients, you control how much you get paid, explains Loren Adler, a fellow at the Center on Health Policy at the Brookings Institution, a nonprofit research organization. UnitedHealth and other insurers argue that they are simply coding patients according to their risk profile and that they comply with Centers for Medicare and Medicaid Services rules.

But they have been accused of abusing the system by coding patients too aggressively. An investigation by the Office of Inspector General of the Department of Health and Human Services found that Medicare insurers received $9 billion in questionable payments in a single year.

For the full commentary see:

David Wainer. “Insurers as Healthcare Providers Risk Conflict of Interest.” The Wall Street Journal (Friday, June 14, 2024): B10.

(Note: ellipses added.)

(Note: the online version of the commentary has the date June 13, 2024, and has the title “What Happens When Your Insurer Is Also Your Doctor and Your Pharmacist.”)

Older Americans, Most at Risk from Covid-19, Were Often Excluded from Mandated Clinical Trials of Therapies and Vaccines

Mandating randomized double-blind clinical trials for Covid-19 candidate therapies or vaccines slowed down the ability of citizens to choose those therapies or vaccines in 2020. Arguably those most hurt by the delay were older Americans age 65 and older, who had the greatest risk of death from Covid-19. The mandated trials slowed availability, but did they at least provide older Americans more and better information about the safety and efficacy of the therapies and vaccines? Not as much as you might suppose. The clinical trials often excluded older Americans because their participation would make the trials more expensive, slower, and less likely to prove safety and efficacy at levels that would result in FDA approval.

(p. D3) “Ideally, the patients enrolled in a randomized clinical trial reflect the demographics of the disease,” said Dr. Mark Sloan, a hematologist leading a Covid-19 drug study at Boston Medical Center, in an email. “Unfortunately, this is seldom the case.”

Now, Dr. Sharon K. Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, is sounding an alarm. She points out that in the race to find drugs and vaccines to fight the pandemic — in which 80 percent of American deaths have occurred in people over age 65 — a substantial proportion of studies may be excluding older subjects, purposely or inadvertently.

“A year from now, when these trials are published, I don’t want to see that there’s no one in them over 75,” she said. “If they create a drug that works really well in healthy 50- and 60-year-olds, they’ve missed the boat.”

She and her team have reviewed 241 interventional Covid-19 studies undertaken in the United States and listed on clinicaltrials.gov, a site maintained by a division of the National Institutes of Health.

They found that 37 of these trials — testing drugs, vaccines and devices — set specific age limits and would not enroll participants older than 75, 80 or 85. A few even excluded those over 65.

. . .

Overall, when Dr. Inouye compiled preliminary results, which have not yet been published, she found that about one-quarter of interventional trials in the United States could exclude or underrepresent older adults.

“To have them be this gravely impacted and not include them is immoral,” said Dr. Louise Aronson, the author of the best-selling book “Elderhood” and a geriatrician at the University of California, San Francisco. “It seems crazy.”

. . .

In clinical trials, “you want to control as many factors as possible,” Dr. Aronson said. Most older adults have other illnesses and take multiple medications, so-called confounding variables that make it difficult to distinguish the effects of the drug or vaccine being studied.

Older people also suffer more side effects. “Nearly all drugs are less toxic when given to younger, healthier people,” Dr. Sloan said in an email. Focusing on them produces fewer adverse effects that must be reported, “and thereby improves chances for F.D.A. approval.”

Physical disabilities, which make it harder for seniors to reach study sites, or hearing and vision impairments requiring large-print forms or audio amplification, can further decrease participation. Investigators may need to take the extra step of obtaining family consent if a patient is incapacitated.

For the full story see:

Paula Span. “The New Old Age; Older Adults May Be Left Out of Some Covid-19 Trials.” The New York Times (Tuesday, June 23, 2020 [sic]): D3.

(Note: ellipses added.)

(Note: the online version of the story has the date June 19, 2020 [sic], and has the same title as the print version.)

After the publication of the NYT article quoted above, Dr. Inouye’s results were published in:

Helfand, Benjamin K. I., Margaret Webb, Sarah L. Gartaganis, Lily Fuller, Churl-Su Kwon, and Sharon K. Inouye. “The Exclusion of Older Persons from Vaccine and Treatment Trials for Coronavirus Disease 2019—Missing the Target.” JAMA Internal Medicine 180, no. 11 (Nov. 2020): 1546-49.

Our Brains Learn in a Process of Continuous Bayesian Updating

(p. A13) First articulated in the 18th century by a hobbyist-mathematician seeking to reason backward from effects to cause, Bayes’ theorem spent the better part of two centuries struggling for recognition and respect. Yet today, argues Tom Chivers in “Everything Is Predictable,” it can be seen as “perhaps the most important single equation in history.” It drives the logic of spam filters, artificial intelligence and possibly our own brains. . . .

At its core, the theorem provides a quantitative method for getting incrementally wiser by continuously updating what you think you know—your prior beliefs, which initially might be subjective—with new information. Your refined belief becomes the new prior, and the process repeats.

. . .

At times Mr. Chivers, a London-based science journalist who now writes for Semafor, seems overwhelmed by an admittedly complex subject, and his presentation lacks the clarity of Sharon Bertsch McGrayne’s “The Theory That Would Not Die” (2011). Yet he is onto something, since Bayes’ moment has clearly arrived. He notes that Bayesian reasoning is popular among “people who come from the new schools of data science—machine learning, Silicon Valley tech folks.” The mathematician Aubrey Clayton tells him that, in the cutting-edge realms of software engineering, “Bayesian methods are what you’d use.”

. . .

It’s notoriously difficult for most people to grasp problems in a structured Bayesian fashion. Suppose there is a test for a rare disease that is 99% accurate. You’d think that, if you tested positive, you’d probably have the disease. But when you figure in the prior—the fact that, for the average person (without specific risk factors), the chance of having a rare disease is incredibly low—then even a positive test means you’re still unlikely to have it. When quizzed by researchers, doctors consistently fail to consider prevalence—the relevant prior—in their interpretation of test results. Even so, Mr. Chivers insists, “our instinctive decision-making, from a Bayesian perspective, isn’t that bad.” And indeed, in practice, doctors quickly learn to favor common diagnoses over exotic possibilities.

. . .

Our brains work by making models of the world, Mr. Chivers reminds us, assessing how our expectations match what we earn from our senses, and then updating our perceptions accordingly. Deep down, it seems, we are all Bayesians.

For the full review, see:

David A. Shaywitz. “Thinking Prior to Thought.” The Wall Street Journal (Thursday, May 15, 2024): A15.

(Note: the online version of the review has the date May 14, 2024, and has the title “‘Everything Is Predictable’ Review: The Secret of Bayes.” In the last quoted sentence I have replaced the word “earn” that appears in both the online and print versions, with the word “learn.”)

The book under review is:

Chivers, Tom. Everything Is Predictable: How Bayesian Statistics Explain Our World. New York: Atria/One Signal Publishers, 2024.

Patient-Reported Health Information Deserves Respect

Patients may have more accurate knowledge of their health than the information found in doctors’ blood tests, as reported in the study summarized below. The credibility of patient self-knowledge provides an added reason, besides respect for freedom, why government should not mandate an individual’s food and drug decisions.

(p. D4) . . . a . . . study . . . suggests that how patients say they feel may be a better predictor of health than objective measures like a blood test. The study, published in Psychoneuroendocrinology, used data from 1,500 people who took part in the Texas City Stress and Health Study, which tracked the stress and health levels of people living near Houston.

. . .

The study found that when people said they felt poorly, they had high virus and inflammation levels. People who reported feeling well had low virus and inflammation levels.

“I think the take-home message is that self-reported health matters,” said Christopher P. Fagundes, an assistant psychology professor at Rice University and a co-author of the study. “Physicians should pay close to attention to their patients. There are likely biological mechanisms underlying why they feel their health is poor.”

For the full story see:

Tara Parker-Pope. “Doctors, Listen to Patients.” The New York Times (Tuesday, July 19, 2016 [sic]): D4.

(Note: ellipses added.)

(Note: the online version of the story has the date July 15, 2016 [sic], and has the title “Doctors Should Listen to Patient Instincts.”)

The academic paper co-authored by Fagundes and mentioned above is:

Murdock, Kyle W., Christopher P. Fagundes, M. Kristen Peek, Vansh Vohra, and Raymond P. Stowe. “The Effect of Self-Reported Health on Latent Herpesvirus Reactivation and Inflammation in an Ethnically Diverse Sample.” Psychoneuroendocrinology 72 (Oct. 2016): 113-18.

Following Salt Consumption Guidelines Increases Risk of Death

Official experts often turn out to be wrong, as in the salt consumption guidelines discussed below. The fallibility of expert knowledge provides an added reason, besides respect for freedom, why government should not mandate an individual’s food and drug decisions.

(p. D4) People with high blood pressure are often told to eat a low-sodium diet. But a diet that’s too low in sodium may actually increase the risk for cardiovascular disease, a review of studies has found.

Current guidelines recommend a daily maximum of 2.3 grams of sodium a day — the amount found in a teaspoon of salt — for most people, and less for the elderly or people with hypertension.

Researchers reviewed four observational studies that included 133,118 people who were followed for an average of four years. The scientists took blood pressure readings, and estimated sodium consumption by urinalysis. The review is in The Lancet.

Among 69,559 people without hypertension, consuming more than seven grams of sodium daily did not increase the risk for disease or death, but those who ate less than three grams had a 26 percent increased risk for death or for cardiovascular events like heart disease and stroke, compared with those who consumed four to five grams a day.

In people with high blood pressure, consuming more than seven grams a day increased the risk by 23 percent, but consuming less than three grams increased the risk by 34 percent, compared with those who ate four to five grams a day.

For the full story see:

Nicholas Bakalar. “Low-Salt Diet as a Heart Risk.” The New York Times (Tuesday, Oct. 11, 2016 [sic]): D4.

(Note: ellipses added.)

(Note: the online version of the story has the date May 25, 2016 [sic], and has the title “A Low-Salt Diet May Be Bad for the Heart.”)

The academic paper reporting the results summarized above is:

Mente, Andrew, Martin O’Donnell, Sumathy Rangarajan, Gilles Dagenais, Scott Lear, Matthew McQueen, Rafael Diaz, Alvaro Avezum, Patricio Lopez-Jaramillo, Fernando Lanas, Wei Li, Yin Lu, Sun Yi, Lei Rensheng, Romaina Iqbal, Prem Mony, Rita Yusuf, Khalid Yusoff, Andrzej Szuba, Aytekin Oguz, Annika Rosengren, Ahmad Bahonar, Afzalhussein Yusufali, Aletta Elisabeth Schutte, Jephat Chifamba, Johannes F. E. Mann, Sonia S. Anand, Koon Teo, and S. Yusuf. “Associations of Urinary Sodium Excretion with Cardiovascular Events in Individuals with and without Hypertension: A Pooled Analysis of Data from Four Studies.” The Lancet 388, no. 10043 (2016): 465-75.