You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Richard Lehman’s weekly review of medical journals

Richard Lehman’s journal review—24 October 2016

24 Oct, 16 | by BMJ

richard_lehmanNEJM  20 Oct 2016  Vol 375

Fainting and pulmonary emboli


O Padua, sidus praeclarum,          O Padua, brilliant star,
hocce nisa fulgido                         
luminous model
virtutum regula morum                  
of virtues and manners,
serto refulgens florido,                  
resting on this radiant wreath of flowers,

te laudat juris sanctio,                    you receive praise from jurisprudence,
philosophiae veritas                      
from philosophical truth,
et artistarum concio,                      
from the artistic community
poematum sublimitas.                  
and from the sublimity of poetry.

So begins Johannes Ciconia’s three part motet from more…

Richard Lehman’s journal review—17 October 2016

17 Oct, 16 | by BMJ

richard_lehmanNEJM  13 Oct 2016  Vol 375
Outcomes and choices
This week’s print NEJM contains mostly papers I’ve already commented on—notably, Gilbert Welch’s important study of mammography and breast cancer outcomes and the landmark British trial comparing surgery, radiotherapy, and watchful waiting for PSA detected prostate cancer (ProtecT).

However, I hadn’t commented on the patient reported outcomes paper that went with this study. This is immensely important because the two papers together provide all the information that men with localised prostate cancer detected by PSA need to make a decision about treatment. If they opt for surgery, they run the highest risk for impotence and urinary incontinence, and this is unlikely to improve over time. If they opt for radical radiotherapy, they run similar risks but the effects tend to improve after six months. They are also likely to have bowel effects, which may resolve to a varying extent. more…

Richard Lehman’s journal review—10 October 2016

10 Oct, 16 | by BMJ

richard_lehmanNEJM 6 Oct 2016 Vol 375
MI: better care counts in long term
Forty years ago, it was generally safer to stay at home with a myocardial infarction. Archie Cochrane demonstrated this in a talk where he deliberately switched his slides round. The cardiologists present declared that the figures mandated the immediate adoption of coronary care units, until Archie told them the improved survival figure applied to those who avoided them. There were cries of “foul,” but he had made his point. The science of outcomes research has improved beyond recognition since then, and nobody has done more to bring that about than Harlan Krumholz at Yale. In a big survey of hospital quality rating and MI outcomes, he and his team show that prompt optimal management not only improves immediate survival, but has life extending benefits for 17 and more years after. more…

Richard Lehman’s journal review—3 October 2016

3 Oct, 16 | by BMJ

richard_lehmanNEJM  29 Sep 2016  Vol 375
Creating a Zika vaccine
In the 15th century, sailors from Cadiz set sail under a captain from Genoa to find the western route from Europe to China. They landed in a New World, and proceeded to infect it with the rich mix of communicable diseases that Spanish sailors of the time were wont to carry. Having ravaged native populations with influenza, measles, and smallpox, they came back and infected Europe with syphilis. Now every major city in the world has an airport that resembles a fleet of ships under Captain Columbus taking off every few minutes. They carry diseased sailors from around the world with amazing speed and efficiency. It is a wonder that any of us are alive. The main reasons are that most viruses are not interested in killing people, and that if they are, we are good at developing vaccines against them. more…

Richard Lehman’s journal review—26 September 2016

26 Sep, 16 | by BMJ

richard_lehmanNEJM  22 Sep 2016  Vol 375

Learning to love data parasites

Back in January, the chief editor of the NEJM joined many other leading journal editors in signing a radical proposal for data sharing tabled by the International Committee of Medical Journal Editors. But at the same time he co-authored an editorial saying that the research community was deeply worried about the prospect of data parasites invading its glorious body of work. Since then, the NEJM has published a good number of Viewpoints expressing different degrees of love or loathing for data parasites. My heart sank at the prospect of reading three more this week, so I decided to listen to Jeff Drazen’s podcast instead (which is a first for me). Having heard the negative gossip about the recent meeting of the International Committee of Medical Journal Editors, I had low expectations. But JD’s tone is very positive. In fact his discussion of the issues is quite similar to those we had five years ago when Harlan Krumholz set three of us to work with him on the Yale University Open Data Access project. The NEJM conversion may be coming late, and it may be too little for some, but it really is progress. And they are backing it up by releasing the SPRINT data. more…

Richard Lehman’s journal review—19 September 2016

19 Sep, 16 | by BMJ

richard_lehmanNEJM  15 Sep 2016  Vol 375

Preherpetic vaccines in the old
For most people who get shingles, the rash and discomfort last for a couple of weeks and then gradually remit. The point of a shingles vaccine is to prevent post-herpetic neuralgia, an uncommon, unremitting condition which can blight people’s lives. Age increases both your chances of getting shingles and the risk of it causing postherpetic neuralgia. The title of this paper is “Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older” and “Medical writing was provided by 4Clinics, France, with funding support from GlaxoSmithKline Biologicals.” So let’s see what effect this vaccine had on rates of postherpetic neuralgia. “In the pooled modified vaccinated cohort that included all participants 50 years of age or older, postherpetic neuralgia developed in 4 of 32 HZ/su recipients and in 46 of 477 placebo recipients with herpes zoster, during a mean follow-up period of 3.8 years.” By slipping in the word “pooled,” the writers from 4Clinics, France have merged two trials and are no longer reporting on ZOE-70 alone, as they did up to this point, but adding in the over-70 subset from ZOE-50. And in so doing they also reveal that in the over-50s trial, there were no cases at all of postherpetic neuralgia under the age of 70. By that token, I can’t see any point in giving the GSK vaccine to people under the age of 70, especially as it causes a local reaction and/or fatigue in the majority of recipients. But maybe that is not the message that we are meant to take away. **See note below** more…

Richard Lehman’s journal review—12 September 2016

12 Sep, 16 | by BMJ

richard_lehmanNEJM  8 Sep 2016  Vol 375
CPAP & CV events
I adore CPAP and bless the night when she arrived in my life. I embrace her—or rather she embraces me—for seven or eight hours of sleepy bliss. I will not hear a word said against her. Does she reduce my risk of cardiovascular events? Probably not, but I couldn’t care less. Here is a trial that randomly assigned 2717 eligible adults between 45 and 75 years of age who had moderate to severe obstructive sleep apnoea and coronary or cerebrovascular disease to receive continuous positive airways pressure treatment plus usual care or usual care alone. Over 3.7 years, “No significant effect on any individual or other composite cardiovascular end point was observed. CPAP significantly reduced snoring and daytime sleepiness and improved health-related quality of life and mood.” It’s remarkable that it even did that, because the mean duration of adherence to CPAP therapy was just 3.3 hours per night. In the NHS, you wouldn’t be allowed a machine if you used it so little. more…

Richard Lehman’s journal review—5 September 2016

5 Sep, 16 | by BMJ

richard_lehmanNEJM  1 Sep 2016  Vol 375
Adding LABAs to steroid inhalers
This week’s print NEJM contains two trials of adding inhaled long acting beta-adrenergic agents to inhaled corticosteroids. The first recruited 6208 children with asthma from the ages of 4 to 11, and compared fluticasone alone with fluticasone plus salmeterol. We know that salmeterol alone should never be given to children, as the accompanying editorial makes clear: “Monotherapy with a LABA in a child should be considered medical negligence, and we suggest that single LABA inhalers should carry a warning to that effect, as required in the United States by the FDA in 2010.” But in this large trial over 26 weeks, serious events did not differ between the group where salmeterol was added to fluticasone and fluticasone alone, and there were no deaths in either group. more…

Richard Lehman’s journal review—30 August 2016

30 Aug, 16 | by BMJ

richard_lehmanAfter a month’s break, I’m catching up with articles of interest in the main non-BMJ journals throughout August. Normal service will be resumed next week. 

NEJM  Aug 2016  Vol 375

No parasites for five years

405   Following its famous “data parasites” editorial last January, the NEJM has struggled to find a comfortable position on the issue of opening up trial datasets for independent analysis. In its first print issue for August it hosted four Viewpoint articles offering a range of options, mainly for the sharing of trials conducted by academic centres. Completely open sharing does not get a mention—the idea that researchers should make their de-identified data available without restriction. The NEJM spectrum instead begins with the Yale Open Data Access project, of which I’m a proud founder member. We pioneered the “academic intermediary” model and still run one for those who wish to use it. If researchers want to use more direct methods of sharing data, we’re hardly going to stop them. But alas, the very opposite tends to be true. A piece from a hitherto unknown body called The International Consortium of Investigators for Fairness in Trial Data Sharing argues that researchers should retain sole use of their databases for up to five years. I’m genuinely sad and baffled that people with prosperous careers supported by public funding can argue that the research they have performed through the altruism of unpaid people taking voluntary risks is somehow their private property. more…

Richard Lehman’s journal review—25 July 2016

25 Jul, 16 | by BMJ

richard_lehmanNEJM  21 July 2016  Vol 375

MenB vaccination for students
220    We’ve been waiting for decades to get a vaccine against Neisseria meningitidis serogroup B. But now that it’s arrived, it’s hardly the kind of thing that gets people looking for champagne bottles in the fridge. It’s an expensive way to prevent a rare disease, and it’s actually quite hard to prove that it has saved any lives so far. This report from its use during an outbreak at “University A in New Jersey” illustrates the problem. Although this paper (and another in Pediatrics) has input from Princeton University, neither actually mentions this august institution by name. I guess this coyness is because it would prefer to be linked in the public mind with Albert Einstein rather than the outbreak of meningococcal disease that began there in December 2013. Nine students were affected and one died. Nearly 6000 were then given meningitis B vaccination and none of the vaccinated students got the disease. more…

BMJ blogs homepage


Helping doctors make better decisions. Visit site

Creative Comms logo

Latest from The BMJ

Latest from The BMJ

Latest from BMJ podcasts

Latest from BMJ podcasts

Blogs linking here

Blogs linking here