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Richard Lehman’s weekly review of medical journals

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…

Richard Lehman’s journal review—2 February 2015

2 Feb, 15 | by BMJ

richard_lehmanNEJM 29 January 2015 Vol 372
407 A Canadian trial tells us a bit more about how to treat raised blood pressure in pregnancy. If women already have elevated BP or acquire it before 34 weeks of gestation without proteinuria, treating to a target diastolic of 100 mm Hg produces the same result as treating to a target of 85, in terms of pregnancy loss, high level neonatal care, or overall maternal complications. Naturally, those treated less intensively show a greater tendency for their BP to rise as the pregnancy continues. more…

Richard Lehman’s journal review—26 January 2015

26 Jan, 15 | by BMJ

richard_lehmanNEJM 22 Jan 2015 Vol 372
331 “Approximately one in four extremely premature infants born at 22 to 28 weeks of gestation does not survive the birth hospitalization; mortality rates decrease with each additional week of completed gestation.” I am not your best guide to this topic, but for those who want to know more, a new study maps trends in the survival of these babies in the USA. The data span from 2000 to 2011 and the 22,248 babies were born in study hospitals within the US National Institute of Child Health and Human Development Neonatal Research Network. I don’t know how typical these hospitals are, but the results differ from the UK Perinatal Mortality Survey in that their deaths from infection have gone down whereas ours have gone up. In both countries, overall mortality has shown a modest fall, but deaths from necrotising enterocolitis have risen.

more…

Richard Lehman’s journal review—19 January 2015

19 Jan, 15 | by BMJ

richard_lehmanNEJM 15 Jan 2015 Vol 372
201 “The main challenge is to ensure better systems [of sharing data] for the future. Because ‘the optimal systematic review would have complete information about every trial—the full protocol, final study report, raw dataset, and any journal publications and regulatory submissions, ‘a prospective system of research governance should insist on nothing less… These changes have been long called for, and delay has already caused harm. The evidence we publish shows that the current situation is a disservice to research participants, patients, health systems, and the whole endeavour of clinical medicine.” more…

Richard Lehman’s journal review—12 January 2015

12 Jan, 15 | by BMJ

richard_lehmanNEJM 8 Jan 2015 Vol 372
113 A vaccine that works really well is the best kind of medical intervention. But a vaccine that gives partial protection is a headache. Sanofi Pasteur has developed a tetravalent vaccine which is 60.8% protective against symptomatic dengue in children in Latin American countries where dengue is endemic. It is least effective in serotypes 1 and 2 and most effective in serotypes 3 and 4, and it is a distinct improvement on previous experimental vaccines against this increasingly common flavivirus. There is a huge market to be tapped, but is this product ready for prime time? The accompanying editorial is very informative on the science but non-committal on the billion dollar question. more…

Richard Lehman’s journal review—5 January 2015

5 Jan, 15 | by BMJ

richard_lehmanJAMA 24-31 December 2014 Vol 312
2659 The effects of extreme heat on older adults: what a great topic for this cold gloomy time of the year. “Heat wave periods (are) defined as two or more consecutive days with temperatures exceeding the 99th percentile of county-specific daily temperatures,” and in this US study they were matched to non–heat wave periods by county and week. This study went right down from the top of Maine to the bottom of Texas, which may account for its rather weak conclusion: “Among older adults, periods of extreme heat were associated with increased risk of hospitalization for fluid and electrolyte disorders, renal failure, urinary tract infection, septicemia, and heat stroke. However, the absolute risk increase was small and of uncertain clinical importance.” more…

Richard Lehman’s journal review—22 December 2014

22 Dec, 14 | by BMJ

richard_lehmanNEJM 18 December 2014 Vol 371
2353 Try to make winter bearable by thinking of the joys of late spring, such as seeing laburnum trees in full blossom. But you need to have plenty of garden space for the brief show they provide, and you also need to warn children against their poisonous seeds. This poison binds to the nicotinic acetylcholine receptors, which, as their name implies, are also the receptors that nicotine binds to. That is why laburnum extract has been sold as an aid to stopping smoking ever since the 1920s, under the name cytisine. Apparently, it is still available in some eastern European countries, but elsewhere we prescribe its vastly more expensive derivative, varenicline. I applaud the NEJM for publishing this open label New Zealand trial in which cytisine was compared with standard nicotine replacement therapy for smoking cessation. It was better. With vaping and cytisine becoming widely available, I really cannot see why combustible tobacco products should remain on the market. more…

Richard Lehman’s journal review—15 December 2014

15 Dec, 14 | by BMJ

richard_lehmanNEJM 11 December 2014 Vol 371
OL The clones! The clones! There is something of Edgar Allen Poe about this study, which describes how “clonal hematopoiesis with somatic mutations is readily detected by means of DNA sequencing, is increasingly common as people age, and is associated with increased risks of hematologic cancer and death.” “Heh, heh,” whispers Vincent Price, “come and look at my clones. No, wait, they are YOUR clones! They lie in wait for you, death lies in wait. Your death. Farewell, my friend. The blessings of old age are necessarily mixed with fear.” But although the NEJM kindly makes this paper freely available to all, together with an editorial about Clone Wars, we are not about to see a new epidemic of haematological malignancies in older patients: we will just understand them better and probably devise new poorly predictive tests to worry people more. A second study spells out the same message. more…

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