Richard Lehman’s journal review—29 June 2015

richard_lehmanNEJM 25 June 2015  Vol 372

2533  The research articles in this week’s print NEJM are all about arcane stuff I’ve covered previously. The Clinical Practice article takes us back to the real world—the one we’d rather not think about, where there is a smell of urine and random cries from rooms down the corridor. How would you like to be cared for if you get advanced dementia? I would like to be in institutional care, and not be a burden to those I love. I would not want to be given antibiotics and I certainly wouldn’t want to be fed artificially. I wouldn’t like to think that my family would have to argue about such things, time and again. But alas, the real world is appallingly bad at caring for people who are dying of dementia. Looking back, I shudder at my complicity in this. “Mrs Bannister’s got a UTI with two plusses of protein and nitrates (sic). Can we have a prescription faxed to Boots?” The printer started whirring before the second sentence was finished. And it’s the same the world over. “In SPREAD, 75% of suspected infections were treated with antimicrobials, but less than half of all treated infections and only 19% of treated urinary tract infections met minimal clinical criteria for the initiation of antimicrobials.” I wish this article was open access, because it would be a fine addition to any Choosing Wisely library.

OL  Three months ago, a Cochrane review appeared that had us all talking over the (excellent) coffee at our weekly meeting in the UK Cochrane Centre. It concluded that “there is currently insufficient evidence to draw definitive conclusions concerning the effectiveness of testing for undiagnosed cancer in patients with a first episode of unprovoked venous thromboembolism (DVT or PE) in reducing cancer and VTE-related morbidity and mortality. The results are imprecise and could be consistent with either harm or benefit. Further good quality large scale randomised controlled trials are required before firm conclusions can be made.” We were all struck by this big gap in the evidence on a common and potentially life threatening situation. But now the gap has been plugged. A big Canadian study compared two strategies following an episode of unprovoked VTE. The first was limited screening for cancer, largely by clinical examination plus chest X ray, and the second consisted of this plus a CT scan of the abdomen and pelvis. The pick-up rate was less than half that seen in previous studies, and it was the same in both groups.

OL  “Less is more” is such a good phrase, and the editorial on the previous study tells us where it comes from. It’s from Robert Browning’s poem Andrea del Sarto, where the Florentine painter describes to his mistress how his work is better than that of 20 more aspirational rivals: “Well, less is more, Lucrezia: I am judged.” Andrea can draw effectively, as they cannot, though their ideas may fly higher. There are several layers of irony in this poem. Lucrezia is actually bored with her lover’s art, though that doesn’t stop him from subjecting her to an endless monologue about it. Browning himself was a famously prolix poet who could never get his ideas down simply. This is a sort of “damn it, why are we doomed to dissatisfaction” piece: do read it if you have the patience, and do have a look at some of del Sarto’s work, which was admired by Michelangelo. Right, now where was I? Ah yes, a paper about bridging anticoagulation. “In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low molecular weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding.” Less is more.

JAMA 23/30 June 2015 Vol 313

2433  I have a personal bias against implantable cardioverter defibrillators, based on the fact that for people with heart failure they prevent sudden death at the cost of making lingering death more likely. And when that occurs they can fire off repeatedly and increase the distress of dying patients. But that’s a one sided view: there is good evidence that they reduce mortality in people with systolic dysfunction following myocardial infarction by up to 30% over the first few years. Here’s a study which shows that fewer than 10% of eligible patients in the US over the age of 65 are fitted with ICDs. And what matters is not what I think but whether they were given the facts and the offer. As the editorial on this paper concludes, “Even though the use of ICDs for primary prevention may not seem to make as much sense for an 80 year old patient as it does for a patient in his or her 50s or 60s, an older patient at risk for sudden cardiac death should have the same opportunity to choose potentially lifesaving therapy.” Can’t argue with that. In shared decision making, more may be more: it’s up to the individual.

2449  Viagra can give you deadly skin cancer. Or it may not. This question is the subject of a nationwide, population based, nested case control study using the Swedish Prescribed Drug Register, the Swedish Melanoma Register, and other healthcare registers and demographic databases in Sweden. The investigators prespecified their hypotheses carefully, and three out of four of them were not proven. Nonetheless, a small but statistically significant association was found between stage 0 melanomas and the use of sildenalfil, vardenafil, or tadalafil. Bear in mind that most of this represents overdiagnosis. Then start speculating about what caused the confounding, if you can be bothered.

2456  I find most articles about medical cannabis vague and boring, as if they were on weed. If this is like really interesting to you man, you like need to read this systematic review and meta-analysis about cannabinoids for medical use in your chill time if you can get over that real high paywall actually. Like they sometimes work for pain—you feel pain?—and spasticity and that stuff. Spasticity—(giggles)—that’s awesome.

JAMA Intern Med June 2015

OL  Cancer boasts the worst trials in medicine. Also the worst drug regulation. Also the worst cost/benefit ratio for new treatments. And also the worst drug toxicities. Plus the highest levels of public and charitable funding. My forehead hits the desk when I read about this stuff. And now in the UK the Saatchi Bill is attempting to make things worse. “Throw anything at them and never mind the cost” may be Lord Saatchi’s idea of science, but it is already harming and bankrupting millions of dying people and making cancer services buckle. Where do patients themselves get a say in this? They will be told something about “new pathways” and “progression-free survival” or else just do what the loudest person in the multidisciplinary team (Am.”tumor board”) tells them to do. Vinay Prasad and colleagues open the can of worms in their systematic review of cancer trials aimed at determining the strength of association between surrogate end points and survival in oncology. “Most trial level validation studies of surrogate end points in oncology find low correlations with survival. All validation studies use only a subset of available trials. The evidence supporting the use of surrogate end points in oncology is limited.” It is high time that control of cancer therapeutics was wrested from the pharmaceutical oligarchs and given to an open community of humane, patient centred medical scientists.

OL  Shock horror. Implantable cardiac defibrillators sometimes don’t shock, so implantees die from ventricular fibrillation. The San Francisco, California, Postmortem Systematic Investigation of Sudden Cardiac Death (POST SCD) study did what it says on its can. Full autopsy, toxicology, histology, and device interrogation were performed on incident sudden cardiac deaths with pacemakers or ICDs. Out of 109 deaths which occurred in people with ICDs during the study, seven were due to device failure: not too shocking, really.

OL  A very large lady aged 50 comes to you complaining of stress incontinence: what kind of procedure should you recommend? The correct answer may well be Roux-en-Y gastric bypass. The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in six geographically diverse clinical centres. Before surgery, 49% of the female patients (with a median BMI of 46) had urinary incontinence. At one year after surgery, the figure had dropped to 18%, though it rose a little to 25% at three years. And bear in mind that unlike all other forms of incontinence surgery, this one is associated with substantial reductions in all cause mortality at 10 years. By the way, a similar incontinence reducing effect also applied to males, though their prevalence was much lower.

Lancet 27 June 2015 Vol 385

2592  “Falls are the most frequent adverse events that are reported in hospitals. We examined the effectiveness of individualised falls prevention education for patients, supported by training and feedback for staff, delivered as a ward level programme.” They describe their study as a pragmatic, stepped-wedge, cluster randomised controlled trial. I never really know what “pragmatic” means. “Stepped-wedge,” I learn, means that an intervention is rolled out sequentially to the trial participants (either as individuals or clusters of individuals) over a number of time periods. Cluster randomised means randomised by unit rather than patients, so that with only eight units involved, confidence intervals are going to be large. OK. So how many old Ozzies hit the ground in each cluster? Well, significantly fewer in those where patients and staff were given the educational intervention. So this sounds like a good idea.

2600  “Pragmatic” is also used to describe this French trial of induction of labour versus expectant management for large for date foetuses. Phew. That comes as a relief to Brits who associate French obstetrics with Michel Odent, whose mysticism about birthing rivals that of Messaien in music and Teilhard de Chardin in biology. To induce or not to induce if the bébé looks insufficiently petit? Induce, I’d say. “Induction of labour for suspected large for date fetuses is associated with a reduced risk of shoulder dystocia and associated morbidity compared with expectant management. Induction of labour does not increase the risk of caesarean delivery and improves the likelihood of spontaneous vaginal delivery. These benefits should be balanced with the effects of early term induction of labour.” Ah, but we must avoid anything that might disconnect the mother from the rapturous noosphere in which the all suffusing Spirit of Nature strives to embrace her in a world of birdsong and ondes martenots.

The BMJ 27 June 2015 Vol 350

“How medicine is broken, and how we can fix it” in less than a thousand words. Ben Goldacre and Carl Heneghan rise mightily to the challenge and everyone should read this piece. I agree with everything, except paying GPs incentives for what is their core function: sharing decisions with patients. That’s like giving a bus driver a bonus for using the steering wheel.

PASTIES. There only used to be one type—Cornish. A thick pastry crust the shape of a quarter circle containing sludgy potato with specks of unidentifiable meat. Fine eating on a drizzly day in some small place beginning with Tre. This week’s BMJ features two trials bearing this name, which is supposed to stand for PAin SoluTions In the Emergency Setting. Truly a Cornish pasty in the Michelin restaurant of acronyms. The first trial shows that people who present in emergency departments with non-traumatic abdominal pain get better pain relief if they are allowed to control their own analgesia. But the second trial shows that this does not apply to people with traumatic injuries. These are useful trials (despite the pragmatic word creeping in again) and deserve a better name. So why haven’t you eaten that half of your pasty? Oh, I’m saving it to feed the seagulls. But the wind whips it out of your hand.

One stillbirth followed by another. Heartbreaking, and common for reasons that we still don’t understand. A systematic review looks at the cohort and case-control studies. Compared with women who had a live birth in their first pregnancy, those who experienced a stillbirth were almost five times more likely to experience a stillbirth in their second pregnancy (odds ratio 4.77, 95% confidence interval 3.70 to 6.15).

Plant of the Week: Philadelphus “Sybille”

The time of mock-range blossom is upon us. Its heady perfume ushers in July, and once it has vanished we shall have to make do with roses, lilies, jasmine, and honeysuckle.

Although this genus contains some fine shrubs with unscented flowers, no normal sized garden should waste space on them when it can host any of a hundred varieties with perfume. Sybille is one of the many bred in fin-de-siècle France (Lemoine of Nancy, ca. 1890). She is petite and sensual, and sprawls as if she has had one absinthe too many.

Don’t be afraid of cutting her branches off and bringing them into the house if you want to luxuriate in her fragrance. All wood that has flowered will need to be removed anyway in the coming month, since the philadelphus flowers on its previous year’s new growth. Few summer garden tasks are more essential to secure strong shoots for the coming year’s portion of bliss.

Editor’s note: When we first published this blog, it incorrectly contained a previous week’s reviews (from 2 March 2015). This has since been published with the correct week’s reviews. We apologise for any confusion.

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