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Richard Lehman’s journal review – 31 January 2011

31 Jan, 11 | by BMJ Group

Richard LehmanJAMA  26 Jan 2011  Vol 305
391   Stroke medicine grew up in the 1990s: like heart failure medicine, it shone welcome light on a large and neglected group of patients with organ damage who had been written off as unsalvageable. This was a Very Good Thing in itself, but its proponents then went on to declare that good stroke care could only be provided in designated stroke units, and went on to run some not-very-randomised trials to prove it. They also began to talk up the evidence for the benefits of immediate thrombolysis, which are real but extremely modest. These fashions spread to the USA following recommendations of the Brain Attack Commission in 2000, and this study evaluates the effect in New York State in 2005-6, comparing mortality and the use of thrombolysis in 31,000 patients with stroke, equally divided between hospitals with or without stroke units. There was a large difference in thrombolysis use – 4.8% in stroke units, versus 1.7% elsewhere; but a very small difference in mortality at 30 days – 10.7% versus 12.5%. It would be nice if someone could go on to look at a wider range of patient-important outcomes too.

391   The Grand Rounds at the National Institutes of Health are not all that grand, just pegs on which to hang some useful clinical reviews. Sarcoidosis is little better understood now than when it was first described in 1899, and the only treatment is to give it a few months of tapered steroids if it gets progressive, which is the case in 30% of cases. Very frustrating, especially as it is quite common, three times as much in black people who also have a worse prognosis. I learnt that here: also that if you look hard enough, you will find skin lesions in 30% of patients, or superficial lymph nodes to biopsy, thus giving you a positive diagnosis. The Kveim test, which used to be mentioned in textbooks, has finally been discarded: only a tissue diagnosis will do, and even that isn’t entirely specific. As for treatment, the authors end their piece on a wonderfully rhetorical note: “Given recent advances in the identification of molecular targets and the emergence of novel therapeutic agents, investigations strategically directed at key immunopathogenic mechanisms should move forward with exigency and resolve.” Exigency! Resolve! Words we need to hear more often! Because current usages of exigency are exiguous.

NEJM  27 Jan 2011  Vol 364
303   One of the nightmare jobs you are glad someone else does is finding veins in haemodialysis patients. A friend who does this from time to time will be very glad to read this study showing that recombinant tissue plasminogen activator is twice as good as heparin at keeping central venous lines open and three times as good at preventing bacteraemia. I shall wish her luck in trying to get the hospital trust to meet the extra cost.

313   The New England Journal allows you free access to this paper on Ventricular Tachyarrhythmias after Cardiac Arrest in Public versus at Home and in case you are inclined to spurn this generous offer, take a look at these excerpts from the editorial about it by Gust H Bardy M.D.:

If CPR were a drug or a surgical procedure, its value would be tested prospectively, but it has not been. Could it be that innovation in the field is hampered by a reluctance to let go of an entrenched approach that has only the appearance of value?

Knowledge of the absolute measured value of CPR would have a profound influence on the direction of research on sudden cardiac arrest and the conservation of resources. More than 40 years after its inception, CPR has never been compared with no CPR in a randomized trial involving patients with sudden cardiac arrest. Although not performing CPR is a heretical idea, it is not unethical; clinical equipoise does exist for the comparison of chest compression with no compression.

Click the links and read on.

332   As an unashamed (nay, passionate) believer in liberal secular values, I think the right to first trimester abortion is a mark of social progress. In the UK, anti-abortion campaigners no longer parade in the streets as I can remember them doing in the 1970s; and it was then as a young GP that I also remember receiving a very biased questionnaire asking if I knew of women whose mental health had been harmed by abortion. Yes, many women are upset by having to go that way, but in terms of lasting harm I can only report that I’ve rarely if ever encountered it. Fortunately you don’t have to rely on my report: here is a massive Danish population cohort study which shows the same rate of psychiatric encounters in the years before and after first trimester abortion.340   Those who are sceptical about the contribution of genomics to the progress of medicine need to read this review article about genomics and the continuum of cancer care (free on the link). We will find many of our prejudices confirmed: knowing a person’s genome helps little in understanding their susceptibility to cancer, except in a couple of well-known instances where a strong family history gave the game away in any case. On the other hand, knowing the genetic aberrations of the cancer itself can be profoundly important, and has allowed many advances in therapeutics and will lead to many more. Avoid confusing the two; and do read James Le Fanu’s book, Why Us?

351   Chronic thromboembolic pulmonary hypertension sounds nasty and almost bound to be underdiagnosed, and indeed it is both. It is fairly easy to spot when it follows acute pulmonary embolism as it does in 2-4% of PEs. But we simply don’t know how often it occurs without overt PE, because much of it may lie hidden as “idiopathic” pulmonary hypertension and not present until right heart failure has set in. By which time it is a bit late: the “heroic” treatment is surgical: “Pulmonary thromboendarterectomy is performed with the use of cardiopulmonary bypass with intermittent circulatory arrest to permit dissection from the main pulmonary arteries to the subsegmental branches.” Not surprisingly, it doesn’t always work, and many patients are too sick to have it done.

Lancet  29 Jan 2011  Vol 377
353   I try to avoid commenting on directly political pieces in these reviews, but when even The Lancet announces The end of our National Health Service, I hope I may be forgiven for letting out a howl. I was Born on the Fifth of July: for American readers, I should explain that this is not a day late, because on the 5th July 1948, the British National Health Service came into being, and for some of us this was a moral statement quite the equal of the Declaration of Independence. Born on its second anniversary, I have been its beneficiary all my life; but now I – and everyone who survives in the UK – must face old age without it, if we fail to stop the destructive process being initiated by this coalition government without any trace of a democratic mandate. In this silly editorial, Horton finds the NHS full of shortcomings and in dire need of change: he cites the study of comparative cancer statistics which he published recently, and which was undermined by its own accompanying editorial and is now elegantly refuted by John Appleby of the King’s Fund on the BMJ website. For a system that has been so unrelentingly battered by politicians over the last three decades, the NHS has shown incredible resilience: just think what it could achieve if it were allowed to be an organic, self-adjusting whole, supported by a separate, democratic (“hypothecated”) system of taxation. It isn’t enough to howl: we need a vision to sustain the best creation in the world.

383   Meanwhile, let us take refuge in the caves where happy gene gnomes mine their data. The latest lode of low grade ore they have discovered is called ADAMTS7 and it contributes to an ore-heap of coronary atherosclerosis genomic risk loci which you can read about in the linked editorial. And soon they can begin all over again! “As in other genome-wide association studies, biological explanations for the identified associations are still not evident. The field of genetics is rapidly moving forward and large re-sequencing studies, with next-generation platforms, will probably compete with or even replace genome-wide association studies as the gold-standard for the identification of disease-related genes or variants.” I literally can’t wait.

393   Eltrombopag! Eltrombopag! O keep it in your doctor’s bag! I sang when I first encountered this orally available thrombopoeitin receptor agonist. It makes you make platelets and so reverses chronic immune thrombocytopenia – as long as you keep taking the tablets. The Lancet has decided to print the RAISE study as it first appeared on their website, despite some second thoughts by its authors – if you like this kind of thing, it’s all explained in an editorial by Lancet house staff. Apparently they made some claims about the inferiority of eltrombopag’s main competitor drug, romiplostim, which may not be sustainable. Plus failing to mention that their patients were splenectomised. Naughtiness.
Eltrombopag! Eltrombopag! Doctor will keep it in his bag,
Depending on what it might cost him -
He might just plump for romiplostim.

BMJ  29 Jan 2011  Vol 342
268   I have a declaration of interest to make about this multi-perspective longitudinal qualitative study of living and dying from chronic obstructive pulmonary disease. I know two of the Edinburgh authors, and their previous narrative research on cancer and heart failure has played a big role in determining how I want to spend the last years of my medical career. At present I’m working with the unique collection of cross-sectional video narratives of 60 illness areas at www.healthtalkonline.org: a gold mine for teaching and service improvement. But these Edinburgh researchers can give you platinum and diamonds, albeit in small quantities because their mining method is so labour-intensive. Longitudinal is how you find lives changing in response to illness and interventions: multi-perspective is how you find out the mismatch between what patients experience and what care-givers think they are providing. I think such mismatch analysis could be the most powerful tool we have for changing attitudes and for achieving real, patient-important improvements in service delivery.

269   Another chap I’m happy to declare a personal interest in is Paul Glasziou, safe and dry in Queensland and one of the best minds in medicine. Here he gets back together with Les Irwig and other Australian colleagues to look at the claim that regular monitoring of serum cholesterol in people taking statins is a good way of checking compliance. It isn’t: it’s irrational, anachronistic and a waste of time and money. Like at least half of the UK Quality and Outcomes Framework.

275   And of course I have to declare an interest in the Easily Missed series, which I helped to set up. I think I may even have suggested Joint Hypermobility Syndrome and I’m certainly glad that it produced such a good contribution, well illustrated and a bit longer than most. Please let’s have your further submissions to keep this series going indefinitely – after all, there’s no end to what you can miss in medicine. But don’t be surprised if we keep your article short and down to ten references.

Arch Intern Med  24 Jan 2011  Vol 171
110   Once our patients are on renal dialysis, we tend to lose sight of them, so keenly do UK renal physicians supervise their sicker patients. I have no idea, for example, why some patients have peritoneal dialysis as opposed to haemodialysis. These are matters best left to experts: especially since, as this US survey shows, it doesn’t make a blind bit of difference.

134    A drug that produces a 41% reduction in recurrent cardiovascular events following myocardial infarction – now wouldn’t that get some marketing! The only drug that comes near that is alcohol – which does get a lot of marketing, but not for that reason. Here there is no drug at all: just talking. Mind you, quite a lot of talking, in the form of 20 two-hour sessions of traditional cognitive behavioural therapy in the first year after MI. Now let’s say this was a new antiplatelet drug produced by pharma, and sold at £115 per month (a generous estimate of the cost of the CBT): every post-infarct patient would be clamouring for it to be funded by the NHS. But it’s only CBT, which is also the best treatment for lots of other things. So forget about ever being able to get it.

151   In every influenza epidemic, sick people with flu get admitted onto wards with other sick people without flu. This French study looked a single big hospital over three flu epidemics. For patients in contact with a health care worker who had flu, the risk ratio for getting flu was 5.5. If you were in a ward with a flu patient, it was 18. If you came into contact with both, 35. This hospital is dangerous: keep out if you can.

166   Here’s a hospital-based study from Spain (and Catalunya, if you’re a Catalan patriot) which may offer some hope of improving antibiotic selection in community-acquired pneumonia. Streptococcus pneumoniae remains sensitive to penicillin while it is often resistant to the macrolides and quinolones which we use with such freedom these days. What we need is a test which reliably rules in S pneumoniae at the time of presentation. The choice of antibiotic in the ambulant patient is oral amoxicillin. The test is urinary pneumococcal antigen testing: let’s have some primary care studies at once, please.

Plant of the Week: Mahonia japonica

In winters that start mild, the lily-of-the-valley scented sprays of this shrub are out before Christmas: this year they are only beginning to show their yellow now. The plant itself is imperturbably hardy and of tremendous vigour. It will grow in poor soil and shade, and it can be cut back at will. It is almost too versatile for its own good. Some affect a preference for its hybrids with the slenderer, tenderer Mahonia lomariifolia, but these are of no greater merit and some of them, unforgivably, have lost their scent in the course of such miscegenation. You lean over them, impaling your eyeball on their spiky leaves, only to find – nothing. Go for the cheap, the tough, the wonderful japonica and accept no substitutes.

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  • Davidbossano

    Hi Richard. I love your blog & usually your judgement but not convinced about hypermobility.
    No evidence is presented to suggest it is other than a variant of normal or that it is a significant factor in pain & fatigue.
    The fact that a big proportion of patients at a tertiary hypermobility service have pain & fatigue isn't that surprising, why else would they be there. Unfortunately no conclusion can be drawn about whether the hypermobility and the other symptoms are associated beyond that expected by chance without looking at a “normal” population.
    Best wishes
    David Bossano

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