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Richard Lehman’s weekly review of medical journals

Richard Lehman’s journal review—6 July 2015

6 Jul, 15 | by BMJ

richard_lehmanNEJM 2 July 2015 Vol 373
11 Liraglutide for weight loss. Like the second Iraq war, we knew for years that it was coming. The propaganda was laid out well in advance. “Obesity is a chronic disease with serious health consequences,” say the NovoNordisk authors. No it’s not, it’s a measure of body weight that carries certain risks. Likewise “pre-diabetes,” which is a blood level that in the majority of people does not lead to diabetes. And diabetes too is just an arbitrarily defined risk cluster, not a weapon of mass destruction. Moreover, if we are going to medicate every fat person in the Western world, we need long term outcome data, not just evidence of a drop in blood glucose and BMI. This 56 week trial recruited 3731 “patients” at 191 sites in 27 countries. Why? You could easily find that number of “patients” with BMI >30 (or >27 if at elevated risk) in any small township in the developed world. Nearly 80% of the people recruited were women. Why? “The sponsor, Novo Nordisk, planned and performed the statistical analyses, [and] provided editorial and writing assistance.” Why? Because everybody does it and the FDA doesn’t mind. Liraglutide will undoubtedly get its licence for use in weight reduction. Three mg daily would currently cost about £200 per month in the UK, and there are at least 15 million Britons who would meet the recruitment criteria of this trial. I make that a potential NHS bill of £36bn annually. Some NICE bargaining lies ahead. Let’s hope they will insist on long term outcome data, with a close look at the cost/benefit ratio and potential harms. more…

Richard Lehman’s journal review—29 June 2015

29 Jun, 15 | by BMJ

richard_lehmanNEJM 25 June 2015  Vol 372

2533  The research articles in this week’s print NEJM are all about arcane stuff I’ve covered previously. The Clinical Practice article takes us back to the real world—the one we’d rather not think about, where there is a smell of urine and random cries from rooms down the corridor. How would you like to be cared for if you get advanced dementia? I would like to be in institutional care, and not be a burden to those I love. I would not want to be given antibiotics and I certainly wouldn’t want to be fed artificially. I wouldn’t like to think that my family would have to argue about such things, time and again. But alas, the real world is appallingly bad at caring for people who are dying of dementia. Looking back, I shudder at my complicity in this. “Mrs Bannister’s got a UTI with two plusses of protein and nitrates (sic). Can we have a prescription faxed to Boots?” The printer started whirring before the second sentence was finished. And it’s the same the world over. “In SPREAD, 75% of suspected infections were treated with antimicrobials, but less than half of all treated infections and only 19% of treated urinary tract infections met minimal clinical criteria for the initiation of antimicrobials.” I wish this article was open access, because it would be a fine addition to any Choosing Wisely library. more…

Richard Lehman’s journal review—22 June 2015

22 Jun, 15 | by BMJ

richard_lehmanNEJM 18 June 2015 Vol 372
2387 For the first time in years, I actually handled a new printed copy of the NEJM last night. What a suave production it is! Flicking though its stylish pages with their subtle sheen, I came across the IMPROVE-IT study once again. It’s a telling reminder of how credulous the medical community can be when faced with a slick presentation of something it wants to believe. No mortality benefit from ezetimibe in over 16 000 very high risk patients over six years. But a borderline significant benefit in a catch-all composite endpoint. Astonishing! Paradigm shift! more…

Richard Lehman’s journal review—15 June 2015

15 Jun, 15 | by BMJ

richard_lehmanNEJM 11 June 2015 Vol 372
2307 Here at last is a study that shows some benefit from out of hospital cardiopulmonary resuscitation. It’s not a randomised trial, since that would be considered unethical, or at least heretical. Instead it comes from interrogating a big Swedish database of outcomes following cardiac arrests outside hospitals. “CPR was performed before the arrival of emergency medical services in 15 512 cases (51.1%) and was not performed before the arrival of EMS in 14 869 cases (48.9%). The 30 day survival rate was 10.5% when CPR was performed before EMS arrival versus 4.0% when CPR was not performed before EMS arrival.” Meanwhile, a big Japanese survey shows that there has been an improvement in outcomes there since resuscitation in the community dropped the “kiss of life” and moved to a strategy based on chest compression only. more…

Richard Lehman’s journal review—8 June 2015

8 Jun, 15 | by BMJ

richard_lehmanNEJM 4 Jun 2015 Vol 372
2185 If you are the sort of exciting doctor who looks after adults with acute hypoxaemic respiratory failure, here is just the article you need. It’s a French trial comparing the effect of high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The three procedures did not result in significantly different intubation rates, but the patients given high-flow oxygen were twice as likely to survive to 90 days. more…

Richard Lehman’s journal review—1 June 2015

1 Jun, 15 | by BMJ

richard_lehmanNEJM 28 May 2015 Vol 372
2087 Now that the NEJM has flagged up its position on conflicts of interest, it’s definitely a case of caveat lector—looking hard at what it decides to publish. First in this week’s issue is a GSK-funded trial of its new herpes zoster vaccine (HZ/su) aimed at preventing shingles in older people. There is already one vaccine licensed for this indication in the USA, but its efficacy falls off the older you are. So there was a plausible gap in the market for older people, which GSK now hopes to fill, since its vaccine is nearly 100% effective at all ages, whereas its rival was only 38% effective over the age of 70. A reasonable trial then, though it would have been better had it used the rival vaccine as an active comparator. The claims of the abstract conclusion are modest and accurate. Not much to pharmascold about then, though I’d like to know how much the journal makes out of selling reprints of papers like this to GSK.

2108 Money can definitely buy people, and cash is generally much more welcome than promises. FIFA could perhaps provide some nice examples, but failing that, here is a study of bribing smokers to give up. They set their trial up as a set of four rational gambler scenarios like those you can read about in Kahneman’s Thinking, Fast and Slow. I’ll leave you to look up the details. The message was that brown paper envelopes, containing 800 bucks and still moist from the sweat of a hand, get results. “Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs.” more…

Richard Lehman’s journal review—26 May 2015

26 May, 15 | by BMJ

richard_lehmanNEJM 21 May 2015 Vol 372
2064 The NEJM has the highest reputation of any medical journal, so it’s impossible not to feel dismay when it lets its standards slip towards the near-nonsensical. When the first part of Lisa Rosenbaum’s three-part series on conflicts of interest appeared, I wondered if it might be some kind of elaborate joke: but sadly it seems not. I hate to see it when a clearly talented young writer is encouraged to write below standard, and at great length for no obvious reason. This final article, “Beyond Moral Outrage,” is an attempt to describe people who worry about conflicts of interest as beyond rationality. In a typical section she writes: “As Haidt concludes, moral reasoning is not ‘reasoning in search of truth,’ but rather ‘reasoning in support of our emotional reactions.'” Interesting that Haidt was actually citing an example not of moral reasoning but of emotional reasoning from the start (unless you count putting the American flag down the toilet as a moral issue), and in which no-one was harmed. Is Lisa actually suggesting that the pharmaceutical industry just flushes away used American flags and has never harmed anyone or concealed harm? But there I go—I am responding to wholly unserious arguments seriously, which I suppose must be the purpose of this exercise. I think the NEJM has shot itself in the foot. And also exposed some awful editorial decisions. Please, if you are going to publish someone attempting to persuade us against bias, don’t let through a sentence like “Being a pharmascold conferred the do-gooder sheen many of us coveted.” The only unbiased words in it are “being,” “a,” “the,” and “of.”


Richard Lehman’s journal review—18 May 2015

18 May, 15 | by BMJ

richard_lehmanNEJM 14 May 2015 Vol 372
1887 Something strange seems to be going on in the New England Journal of Medicine. This week it publishes two trials of gene therapy for Leber’s congenital amaurosis, one at the start and the other at the end of its research section. Neither of them achieved more than fleeting benefit in one genetic variety of an uncommon form of blindness, which can be caused by mutations of at least 19 different genes. It takes a long editorial to explain to generalist readers what this is all about and why it may never work. I am all for publishing negative results, but I’m not sure most of us really needed to know this right now. more…

Richard Lehman’s journal review—11 May 2015

11 May, 15 | by BMJ

richard_lehmanNEJM 7 May 2015 Vol 372
1860 This week the NEJM is offering everyone a free lunch, in the form of an open access article and editorial on the theme of “Re-interpreting Industry-Physician Relationships.” But as everyone knows, there is no such thing as a free lunch, especially when it comes to relationships between doctors and the pharmaceutical industry. So what is going on? The key lies in the word “re-interpreting.” Using two straw-man examples and one real one (Vioxx), Lisa Rosenbaum, a national correspondent for the journal, seeks to show that too many people are cognitively biased towards an “Ugly House” interpretation of the pharmaceutical industry. She intends to develop this theme in two further essays, warmly commended to our attention by her editor Jeff Drazen. The only conflicts of interest they declare are their ties to the NEJM. But that is a pretty massive conflict, isn’t it? How much of the NEJM‘s income comes from reprint sales to the pharmaceutical industry? Sorry, I didn’t catch that… commercial confidentiality?—ah, I see. more…

Richard Lehman’s weekly journal review—5 May 2015

5 May, 15 | by BMJ

richard_lehmanNEJM 30 April 2015 Vol 372
1684 “Virtual Visits—Confronting the Challenges of Telemedicine” is a Perspective piece which starts full of optimism about the potential of telemedicine and then switches tack half way through. “For providers, using telemedicine may be more efficient than seeing patients in brick-and-mortar offices, since it reduces the time and space needed to run a medical practice. For patients, telemedicine can reduce travel expenses and the opportunity costs associated with obtaining care, such as missed hours or days of work.” Actually, that sounds unlikely on first principles. Could telemedicine really save on time and office space? Won’t the great majority of medicine always have to be a direct human interaction? What proportion of illnesses actually lend themselves to remote consultations and how many ill people would rather use a device than see a doctor face to face? Sure enough, when trials have been done—even in convenient chronic conditions with e-savvy populations—they have failed to show any improvements in outcomes and have usually increased service use and costs. Telemedicine may seem like the shiny future, but in reality it is a return to the Middle Ages. Those who could afford a physician would get examined by his clerk, who would take the history, measure the pulse, examine the urine, and report to his gowned master. The physician himself was far too important to actually touch a patient. more…

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