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Richard Lehman’s weekly review of medical journals

Richard Lehman’s journal review—13 April 2015

13 Apr, 15 | by BMJ

richard_lehmanNEJM 9 Apr 2015 Vol 372
1389 The major trials of coronary artery thrombus aspiration for myocardial infarction are TAPAS, TASTE, and TOTAL. Think of a bar crawl in Seville. The TAPAS and TASTE are obvious, and TOTAL could refer to the bill, which is sometimes just chalked on the surface you’re leaning on, or to your state of inebriation after eight glasses of fino sherry. Either way, these bars are more interesting than this procedure, which is now ready for burial as a routine intervention for MI. Both TASTE and TOTAL find that it does not improve cardiac outcomes and TOTAL finds an increase in stroke. The accompanying editorial thinks it may yet prove of benefit to high-risk patients, citing observational follow-up and post-hoc subgroup analysis. Maybe one further trial needed in such patients before saying ADIOS to the bartender. But why does cardiology come up with so many failed hopes? It seems so obvious that sucking out a clot as soon as it has blocked a coronary artery will be of benefit, but it just isn’t. Even procedures we believe in, like timely percutaneous intervention for MI, aren’t having the impact we hoped for. The editorial also points out that, “Although door-to-balloon times have improved significantly over the past 10 years, in-hospital mortality for STEMI has remained virtually unchanged.” more…

Richard Lehman’s journal review—7 April 2015

7 Apr, 15 | by BMJ

richard_lehmanNEJM 2 April 2015 Vol 372

372 In English nursery rhyme, it is traditional for a Duke to have 10 000 men. Here is a trial from Duke University that recruited 10 000 men and women, and allowed in a further three for extra measure. These 10 003 recruits were those “whose physicians believed that nonurgent, noninvasive cardiovascular testing was necessary for the evaluation of suspected coronary artery disease.” That is a fate which befalls a staggering four million Americans every year. These people were randomised to be investigated either by coronary computed tomographic angiography or functional testing, which in almost every case meant exercise ECG. I struggled a little with some of the figures, but I broadly agree with the conclusion: “In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of two years.” But I do just wonder how many of these people really “required” testing in the first place. more…

Richard Lehman’s journal review—30 March 2015

30 Mar, 15 | by BMJ

richard_lehmanNEJM 26 Mar 2015 Vol 372
1193 Is the NEJM preaching Socialism? “We believe that all financial incentives and logistic barriers to providing the least expensive drug, among drugs equivalent in safety and efficacy, should be eliminated so that patients may benefit fully from the results of this Diabetic Retinopathy Clinical Research Network trial as well as those from other comparative trials.” more…

Richard Lehman’s journal review—23 March 2015

23 Mar, 15 | by BMJ

richard_lehmanNEJM 19 Mar 2015 Vol 372
1093 “All bacteria will be susceptible to common cheap antibiotics by 2050″ is not a headline you will see in any newspaper. But I’d like you to think seriously whether this is not more likely than the widely-touted doomsday scenario of a post-antibiotic era in which we are all endangered by untreatable bacterial infections. Very few bacteria are pathogenic to humans, and those which are simply adapt to the environments we create for them. Staphylococcus aureus quickly became resistant to penicillin after it was widely introduced into hospitals and the community in the 1950s. Then in 1959 Beecham marketed meticillin as a beta-lactam antibiotic to deal with penicillinase-producing strains of S aureus. Its replacement, flucloxacillin, remains active against most staphylococcal infections in the UK, but not in the USA, where skin and tissue infections are now most commonly caused by meticillin-resistant staphylococci (MRSA). But this study shows that these infections respond well to treatment with either clindamycin or trimethoprim-sulfamethoxazole (co-trimoxazole) and that there is nothing to choose between these two cheap old antibiotics in terms of efficacy or safety.

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Richard Lehman’s journal review—16 March 2015

16 Mar, 15 | by BMJ

richard_lehmanNEJM 12 March 2015 Vol 372
1009 Stroke is a wonderfully straightforward word. When used in a medical context, everybody thinks of a sudden blow. It is something that needs swift action. But actually “stroke” isn’t a straightforward word: ask the cat that has just jumped on to my lap. Now it means a slow and pleasurable process in which she purrs while I pass my hand along her back. That’s the problem with words with deep Indo-European roots: the *streig root is well preserved in several languages, but over thousands of years it has come to mean almost opposite things. And brain strokes can vary between anything from a hammer stroke, which obliterates life, to a brush stroke, which causes some local weakness for a few days. The problem lies between the two ends, and in the need for investigations and treatment to be done at great speed. Two trials of endovascular therapy for ischaemic stroke with perfusion imaging selection in this week’s NEJM present a major advance in stroke treatment, but also illustrate these difficulties. The interventions compared in the first trial (mainly Australian and publicly funded) were intravenous alteplase within 4.5 hours with or without endovascular thrombectomy using the Solitaire FR (Flow Restoration) stent retriever. The patient groups had a mean age of 68 and 70 (the groups were not perfectly matched), and had occlusion of the internal carotid or middle cerebral artery, and evidence of salvageable brain tissue and ischaemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The trial was stopped prematurely because the thrombectomy group showed markedly better neurological improvement at three days and 90 days. more…

Richard Lehman’s journal review—9 March 2015

9 Mar, 15 | by BMJ

richard_lehmanNEJM 5 Mar 2015 Vol 372
893 “A Precious Jewel—The Role of General Practice in the English NHS” is an essay by Martin Marshall from University College, London. It is open access, and the best summary I have read of the plight of general practice after the maulings of the last few years. Without being polemical, Marshall makes it very clear that all the elements which patients want, and which should shape the medicine of the future, are already present in UK general practice, but are being rendered ever less possible to deliver. more…

Richard Lehman’s journal review—2 March 2015

2 Mar, 15 | by BMJ

richard_lehmanNEJM 26 February 2015 Vol 372
803 It’s hard to imagine a world without chocolate, potatoes, tomatoes, avocados, sweet peppers, and chilli peppers. Since the 16th century, one or more of these excellent South American foods has become a characteristic ingredient of almost every national cuisine from Northern Europe to Thailand. The peanut or tlalcacahuatl was an equally ancient item of the Mesoamerican diet, but it only started being widely fed to humans rather than livestock in the last 80 years, after it was taken up in the USA in the 1930s. Arachis hypogaea, the modern cultivar, seems to have originated in Paraguay but is now most heavily produced in China. It is an insipid product of no culinary merit, but people seem keen to feed it to their children. If they are to do this, then the sooner they start the better. Babies aged 4-11 months who were skin-prick negative to peanuts remained so in 98% of cases at the age of 5 if they were fed peanuts right away, whereas if peanuts were avoided altogether, 13.7% of the kids were allergic at 5. In initially skin-prick positive group, avoiders ended up allergic in 35% of cases compared with 11% who started peanut eating in their first year. So peanut consumption by humans should either cease, or begin in infancy. more…

Richard Lehman’s journal review—23 February 2015

23 Feb, 15 | by BMJ

richard_lehmanNEJM 19 Feb 2015 Vol 372
703 In our syphilis lecture at medical school we were told that immigrants coming to the United States of America in bygone days were quarantined on Staten Island and had to undergo testing for Treponema pallidum using the Wassermann Reaction. An unlucky few would test positive not because they had venereal syphilis but because they had yaws, an infectious disease caused by Treponema pallidum subspecies pertenue. I don’t think I have given yaws another thought in the intervening 42 years, but I now learn that it is still very much around in 12 countries in Africa, Asia, and the western Pacific region. It is transmitted by direct skin-to-skin, nonsexual contact and causes a chronic, relapsing disease that is characterized by highly contagious primary and secondary cutaneous lesions and by noncontagious tertiary destructive lesions of the bones. It mostly affects children: hence this trial of single-dose azithromycin in children under the age of 15 on a Papua New Guinean island on which yaws was endemic. Its prevalence dropped steeply and there was no sign of emerging macrolide resistance in the little treponemes. more…

Richard Lehman’s journal review—16 February 2015

16 Feb, 15 | by BMJ

richard_lehmanNEJM 12 Feb 2015 Vol 372
601 A couple of months ago I went all Edgar Allen Poe about clones in the bone marrow—clones, bones and groans in fact. Watching the processes that lead up to myeloproliferative disaster is like watching evolution on fast-wind, a point well made in an editorial about this first study in the NEJM. If you could go back to the Cambrian period and stand in the seas that formed the Burgess Shales, you could pick out animal life forms that contained most of the structural features that animals have today. But it took 500 million years of eating each other, invading land, being wiped out by climate change and asteroids, feeding off novel plant species, learning to fly, etc before they became what they are today. Nothing could have been predetermined: a lot of it led nowhere, or to mighty things long gone: and it is so in your bone marrow. “We determined mutation order in patients with myeloproliferative neoplasms by genotyping hematopoietic colonies or by means of next-generation sequencing. Stem cells and progenitor cells were isolated to study the effect of mutation order on mature and immature hematopoietic cells.” And here comes the lesson in evolutionary biology: “The age at which a patient presented with a myeloproliferative neoplasm, acquisition of JAK2 V617F homozygosity, and the balance of immature progenitors were all influenced by mutation order.” more…

Richard Lehman’s journal review—9 February 2015

9 Feb, 15 | by BMJ

richard_lehmanNEJM 5 Feb 2015 Vol 372
519 Refractory angina seems to be common in cardiac clinics but not in primary care. When all the drugs have failed, and revascularization is not an option, device makers like to get inventive. The latest gizmo is an hour-glass shaped expandable metal object which sits at the portal of the coronary arteries and “creates a focal narrowing and increases pressure in the coronary sinus, thus redistributing blood into ischemic myocardium.” My inclination is to say “Yeah, right,” but these things do seem to work, somehow or other. “The device was also associated with improvement of at least one Canadian Cardiovascular Society angina class in 71% of the patients in the treatment group (37 of 52 patients), as compared with 42% of those in the control group (22 of 52) (P=0.003).” The control was a sham procedure. more…

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