JAMA 15 May 2013  Vol 309
2016    I got into a bit of a muddle with this paper, but I blame JAMA. Let me test you out: the abstract says “Long-term follow-up of the randomized, masked 2-year Colpopexy and Urinary Reduction Efforts (CARE) trial of women with stress continence who underwent abdominal sacrocolpopexy between 2002 and 2005 for symptomatic POP and also received either concomitant Burch urethropexy or no urethropexy.” Then in the first section of the full text the cohort is described as from a “multicentre, randomized, masked trial in women without stress urinary incontinence (SUI).” Because I’ve never before heard women described as being “with stress continence,” and then randomized to incontinence surgery, my mind supplied the prefix “in.” Did yours? Anyway, let’s get this quite clear: the women in this study had pelvic organ prolapse without stress incontinence and they all got a procedure called abdominal sacrocolpopexy, by which the vaginal vault is fixed to the sacral anterior longitudinal ligament. Half of them also got the procedure called Burch urethropexy to support the urethra and hopefully prevent stress incontinence. They were asleep during the procedures and not told whether or not they had the Burch procedure. Stay with me—we are nearly there. At seven years, a lot of the sacrocolpopexy procedures had come adrift anatomically and the women who had the concomitant Burch procedure had less stress incontinence. So are you now clear about the message of this paper for patients and general clinicians? I can’t say that I am, but it is a nice piece of work and I hope that it will be of interest to urogynaecologists and those in the IDEAL collaboration who study surgical trial methods. more…

JAMA  8 May 2013  Vol 309
1903    When an implanted cardioverter defibrillator goes off inside you, you are sure to feel deeply shocked: whereas, for others, watching you drop dead might be even more shocking. One needs to strike a balance. That was the purpose of the ADVANCE III (Avoid Delivering Therapies for Nonsustained Arrhythmias in ICD Patients III) trial. Essentially this was a gamble on how many ventricular tachycardia beats are allowed to happen before the device fired: with current devices it is usually 18-24, whereas in this trial half the patients got a newly programmed device which counts to 30-40. They stayed alive as much, didn’t have more syncopal episodes, and had a third fewer shocks in the first year.
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JAMA  1 May 2013  Vol 309
This week’s JAMA is devoted to child health. This was a mistake, because although children are generally interesting, health generally is not. A study from Quebec tries out various doses of vitamin D in babies and finds you can only get to a reliably high value by using doses which might cause hypercalcaemia. I’m not sure how many generalist readers need to know this. Likewise it’s faintly interesting that two doses of human papillomavirus vaccine given between the ages of 9 and 13 may give the same immunogenicity as three given between 16 and 26, but as we don’t definitely know how long this lasts from the trial, nobody is going to change practice. But among the skim-and-flick-past articles there is one important one, which brings good news for the parents of very premature babies.

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JAMA  24 Apr 2013  Vol 309
1691  Last week I welcomed the imminent arrival of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) because it would classify every human being as insane, and so should provide the world with a good opportunity to step back and decide what psychiatry is really about. This open access piece about the new manual is written by DSM enthusiasts, so do read it and make up your own minds, because on my own admission there is a high probability that I am insane. And naturally, the same applies to you.
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JAMA  17 Apr 2013  Vol 309
1607   Why do some babies get colic every evening until they are about three months old? Dunno. Why do some children and adolescents get migraine? Dunno. Connect the two dunnos and you get a third—why are children and adolescents who get migraine six times more likely to have a history of infantile colic? That’s the discovery of an Italian study based on children aged 6 to 18 attending emergency departments for migraine: just a reminder of how little we understand about either condition. more…

JAMA  10 Apr 2013  Vol 309
I try my best, dear Reader, oh I do. When I see an issue of JAMA devoted to Genomics, I don’t just sigh deeply: I brew the coffee and get stuck in. This is the future and it needs to work; the doctor of tomorrow will see this as the dawn of a great new age. Or so they tell us: but I defy you to find a scrap of immediate clinical relevance to hang on to in this batch of research papers which have held me in detention for the last hour: more…

JAMA  3 Apr 2013  Vol 309
1355    With the runaway success of the Alltrials petition, it may seem as if everyone in the world has now agreed on the need to share every bit of data relating to every medical device and product used on millions of patients every day. In reality, this is going to be a very slow process, involving hard work over many years. Nobody is more aware of this than Joe Ross and Harlan Krumholz, whose YODA project is pioneering the methodology needed to do the job properly, in a way that few others have even considered attempting. The imperative to do this work is absolute, and is beautifully set out by them in this Viewpoint article. But the editor of JAMA, Howard Bauchner, announced in Oxford that he is planning to sit on the fence about Alltrials a while longer, consulting his editorial board in a few months’ time. In the meantime we can look forward to a piece on the “unintended consequences” of data disclosure by Robert Califf some time soon. more…

JAMA  27 Mar 2013  Vol 309
1241    Have you ever heard of someone who’s recently had a heart attack going off and having 40 infusions of disodium ethylenediaminetetraacetic acid, ascorbate, B vitamins, electrolytes, procaine and heparin? No, I hadn’t either, until I went to give a talk to some cardiac rehabilitation patients about 12 years ago. more…

JAMA  20 Mar 2013  Vol 309
1125    Is aliskiren a good drug for heart failure? Despite the negative result of this Novartis-funded trial (ASTRONAUT), I think the answer is probably yes. First of all, let me remind you that aliskiren is a direct renin blocker. In other words, it acts right at the start of the renin-angiotensin- aldosterone cascade. But unfortunately for alis and her sister kirens, these renin blockers have come on the scene too late. We already have perfectly good RAAS inhibitors in the form of ACE inhibitors, ARBs, and aldosterone blockers, and between them they do all that it is possible to do via RAAS inhibition in heart failure: which, by the way, is not much, since typical NNTs lie over 30. Now imagine a world where renin blockers were first on the scene, and we selected patients for heart failure trials on the basis of BNP rather than ejection fraction; then this trial would probably have been a resounding success. Because the ASTRONAUT groups were not well matched: the patients put on aliskiren had a mean NT-BNP of 4239 pg/ml compared with 2718 pg/ml in the placebo group: in other words, they were experiencing considerably worse ventricular strain. Yet they still had better outcomes than the less ill controls, albeit not to the point of statistical significance. If you removed all the ACE inhibitors, ARBs, and the amazing amount of mineralocorticoid blockade (57%) from these patients, there would probably have been a very significant benefit in mortality and readmission from aliskiren. But life is unfair, and Novartis may just have to face the fact that Alice has come too late to lead them into Wonderland: though a trial in heart failure with preserved systolic ejection fraction, but without diabetes, might be interesting.
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JAMA  13 Mar 2013  Vol 309
997   Obstructive sleep apnoea is very, very common. In the preamble to this Australian study, a third of the adult population is accused of having symptoms that might be OSA. Previous studies have shown that polysomnography has no significant advantages over a home video, reporting by sleeping partners, or a trial of self-titrated continuous positive airways pressure. So the question arises whether specialist sleep clinics are really needed, or whether a sleep service of equal effectiveness can be provided in primary care. In this randomized non-inferiority study, the results of the two modes of care were equally good. So come on, enterprising commissioning GPs: buy a few CPAP machines and offer a local service. Nobody seems to care about conflicts of interest any more, and I guess if this coalition lasts a year or two more, you’ll be able to charge patients at the door on the grounds that OSA is “just snoring” and not worthy of NHS provision. In fact it is a powerful cardiovascular risk factor and a major prognostic indicator e.g. in heart failure.
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