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Richard Lehman’s weekly review of medical journals

Richard Lehman’s journal reviews—27 June 2016

27 Jun, 16 | by BMJ

richard_lehmanNEJM  23 Jun 2016  Vol 374

Adolescent BMI: big data, little meaning
2430  “How might adolescent BMI affect adult cardiovascular mortality? In our study, we could not control for important risk factors (e.g., smoking, exercise, and physical fitness) or for adult BMI.” Ah, a slight problem then. This study tells you the exact correlation between adolescent body mass index in 2.3 million Israeli Jewish males and cardiovascular mortality up to 40 years later. Overall, less than a tenth of deaths in these men were cardiovascular. They were more likely to die this way if their BMI was over the 50th centile when they were about 17 years old. However, when you can’t even adjust for obvious confounders, what does this actually mean? more…

Richard Lehman’s journal reviews—20 June 2016

20 Jun, 16 | by BMJ

richard_lehmanNEJM  16 Jun 2016  Vol 374
Data about parasites
2335   I love it when it’s parasite time in the NEJM. Tenaciously clinging to the wall of the large bowel, tapeworms suck up the digested food that North Peruvians have carefully gathered and prepared, just like people who reanalyse or meta-analyse data that others have gone to the trouble of producing. Such tapeworms—I mean the Peruvian kind—can be eliminated by a number of strategies. The ones considered here involved screening of humans and pigs, antiparasitic treatment, prevention education, and pig replacement in 42 villages. A scaled up strategy of mass antiparasitic drugs for humans and Taenia solium vaccination for pigs eventually did the trick. At the end of the exercise hardly any village pigs were found to contain meta-analysts. I mean T solium cysts. more…

Richard Lehman’s journal reviews—13 June 2016

13 Jun, 16 | by BMJ

richard_lehmanNEJM 9 Jun 2016 Vol 374
All sorts of AML
2209 Ernest Rutherford (1871-1937), New Zealand’s greatest son, said that physics is the only science, and the rest is just stamp collecting. Nowadays physics seems largely about making stuff up, so I feel safer with the stamp collectors. And what wonderful stamps they are finding every day! When you were a student with your medical school stamp album, there was just one Penny Black, called Acute Myeloid Leukaemia (AML). Now they’ve looked at the watermarks and all that sort of thing and it turns out that there are 76 types of Penny Black or AML. And this, of course, matters a great deal if you happen to have one of them. more…

Richard Lehman’s journal reviews—6 June 2016

6 Jun, 16 | by BMJ

richard_lehmanNEJM 2 Jun 2016 Vol 374
Germs, catheters and hospitals
2111 Anyone who has an indwelling urinary catheter will get bacteriuria, sooner or later. I was taught this as a medical student, as a medical HO and urology SHO, and observed it through 35 years as a GP. This article begins by stating that up to 69% of catheter-associated UTIs are considered to be avoidable, provided that recommended infection-prevention practices are implemented. It’s the kind of claim that begs questions: is asymptomatic colonisation the same as “UTI”? Is this a statement about hospitals, or the community, or nursing homes, or all three? Still, it’s hard to argue against taking precautions against introducing organisms into the urinary tract, especially in already sick patients in hospital. And a prevention package may work, according to this carefully reported before-and-after study. Data were obtained from 926 units in 603 American hospitals as they introduced a program designed to reduce catheter infection. Infections went down on the wards but not on intensive care units. more…

Richard Lehman’s journal review—31 May 2016

31 May, 16 | by BMJ

richard_lehmanNEJM 26 May 2016 Vol 374
An end to oncology drug madness?
2001 “Seamless Oncology-Drug Development” is a viewpoint piece about the research and regulatory changes that have allegedly been driven by a desire for “early access to transformative new anticancer drugs.” To my simple way of thinking, this would mean first showing that the new drug was transformative, through large double-blinded randomised controlled trials demonstrating a sizeable survival benefit. Secondly, in order to achieve “early access,” the drug would then be immediately available to all patients, and charged at production cost to the health provider. Thirdly, further trials would be conducted using it earlier in the disease process, compared to existing standard treatment. more…

Richard Lehman’s journal review—23 May 2016

23 May, 16 | by BMJ

richard_lehmanNEJM 19 May 2016 Vol 374
Danazol & the Norns
1922 In early European mythology, life was seen as a fragile string, which could be cut by an arbitrary force outside the power of the gods. In the Greek version, a child would be visited on the third day of life by the three Moirai. Clotho spun the thread of human fate, Lachesis dispensed it, and Atropos cut it at the appointed moment of death. In Norse mythology, these ladies took the form of Norns. Nowadays Clotho dispenses telomeres at the end of DNA strands. With each cell division, these shoelace ends become shorter, and eventually Atropos steps in with her abhorred shears and you die. Lachesis sometimes causes mischief by handing out telomeres that are too short, causing people to be highly susceptible to cancer or to die prematurely from bone marrow failure, liver cirrhosis, and pulmonary fibrosis. more…

Richard Lehman’s journal review—16 May 2016

16 May, 16 | by BMJ

richard_lehmanNEJM 12 May 2016 Vol 374
Smoake is dangerous to ye Lungs
1811 A new study of smokers with preserved pulmonary function finds that a lot of them have lung symptoms. And even if they don’t fulfil the criteria for chronic obstructive pulmonary disease (COPD), they still experience the familiar pattern of exacerbations and limitation of activity and end up using the same medications as people with COPD. Nothing has changed in the 412 years since King James I of England declared smoking to be “A custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs, and in the blacke stinking fume thereof, neerest resembling the horrible Stigian smoke of the pit that is bottomelesse.” more…

Richard Lehman’s journal review—9 May 2016

9 May, 16 | by BMJ

richard_lehmanNEJM 5 May 2016 Vol 374

Cholera: still not defeated
1723 Endemic cholera is one of those diseases that remind us how unequal the world still is. Cholera from the Indian subcontinent swept Europe in the 1820s and 30s but had virtually disappeared a few decades later, due to improvements in our water supply. Yet it still kills tens of thousands of people in the lands of its origin. It’s taken more than a century of effort to produce a modestly immunogenic vaccine like the one trialled here. This is the killed whole-cell-only oral cholera vaccine called Shanchol which was introduced in 2009 and costs $1.85 per dose. The present trial was conducted in the slums of Mirpur, Dhaka, where endemic cholera typically peaks during March and April and the highest rates are seen in young children. Its purpose was to study the effect of using a single dose only. The protective efficacy over 6+ months was 40% against all cholera episodes, and 63% against severely dehydrating cholera episodes in older children and adults, but much lower in children under five. So in the second decade of the twenty-first century, we still don’t have a good method of protecting the most vulnerable group from cholera. Oh, hang on, we do. Give them a clean water supply. more…

Richard Lehman’s journal review—3 May 2016

3 May, 16 | by BMJ

richard_lehmanNEJM 28 April 2016 Vol 374
Colon cheer
1605 As we get more affluent, we drink more alcohol, grill more meat, grab bacon or salami sandwiches for lunch. Up in heaven, a wrathful god looks on and smites us with bowel cancer. Oh wait, no, he seems to be easing off: for all our sins, the incidence of bowel cancer has dropped by 45% from its peak in the mid-1980s. This is not due to screening, as Gil Welch and Doug Robertson explain in the most interesting article in this week’s NEJM. I don’t see how it can be diet either. We don’t know why colorectal cancer is getting rarer: it’s another of those happy conundrums in the history of cancer epidemiology. more…

Richard Lehman’s journal review—25 April 2016

25 Apr, 16 | by BMJ

richard_lehmanNEJM 21 April 2016 Vol 374

Aliskiren in Cardioland

1521 What does the R in the RAA pathway stand for? I used to pose this question in lectures several times a year, believing all that I had been told about the importance of the renin-angiotensin-aldosterone pathway in heart failure. I’d explain that we had drugs which blocked the AA but not the R. Then, a few years ago, along came aliskiren, a direct renin inhibitor. But early trials raised fears that poor Alice had come too late to the party. And this trial in people with chronic heart failure and reduced ejection fraction really pushes her down the rabbit hole. “In patients with chronic heart failure, the addition of aliskiren to enalapril led to more adverse events without an increase in benefit. Noninferiority was not shown for aliskiren as compared with enalapril. (Funded by Novartis; ATMOSPHERE)” shouted the Queen of Hearts. “Not non-inferior, not non-inferior” squawked the Mad Hatter. Alice went to look for her friend the Walrus, because she couldn’t stand the atmosphere any longer. more…

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