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Richard Lehman’s weekly review of medical journals

Richard Lehman’s journal review—5 December 2016

5 Dec, 16 | by BMJ

richard_lehmanNEJM  1 Dec 2016  Vol 375
Can genes prove how drugs work?
Medicine is the application of neat science to a messy world. We love it when it works simply: for example, when a single gene controls a single biochemical process, which we can then block with a single chemical. Statins are often cited as an example: they block 3-hydroxy-3-methylglutaryl–coenzyme A reductase, an enzyme that is governed by the HMGCR gene. By doing so, they reduce circulating levels of low density lipoprotein cholesterol (LDL-C) and, bingo, down goes your cardiovascular risk. But for less obvious reasons, they also raise blood glucose slightly and cause muscle symptoms in many people. If your glucose is highish to start with, they may cause you to “get diabetes,” i.e. cross an artificial threshold and bundle you together with millions of different people with this scary label. But can all this really be put down to the HMGCR gene? Here’s a population study, which concludes that it can, provided you throw in a second gene locus governing LDL-C levels. more…

Richard Lehman’s journal review—28 November 2016

28 Nov, 16 | by BMJ

richard_lehmanNEJM  24 Nov 2016  Vol 375


It grieves me to say it, but there are certain things that American medicine does better than British medicine. Repairing abdominal aortic aneurysms seems to be one of them. It’s not that men on the whole live longer over there, but only a third as many die from a ruptured AAA in the USA as in England, according to a study using linked databases on both sides of the ocean. In America they tend to go in and repair at 58mm whereas we tend to wait until 64mm, and they do twice as many repairs, suggesting a screening effect. Perhaps as our screening programmes gather momentum, we will see a gradual levelling of difference; but for the time being, America definitely trumps England. Damn, I must learn to stop using that expression. more…

Richard Lehman’s journal review—21 November 2016

21 Nov, 16 | by BMJ

richard_lehmanNEJM  17 Nov 2016  Vol 375
Diabetes kills in Mexico City
“Overall, between 35 and 74 years of age, the excess risk of death associated with diabetes accounted for approximately one third of all deaths from vascular causes and one third of all other deaths.” That is a shocking statistic and it applies to the largest conurbation in the northern half of the Americas. People in Mexico City have high rates of diabetes and a third of people with it run glycated haemoglobin levels above 10. That is too high, even in my belief system. I also believe that duration and rate of progression are the most important factors in type 2 diabetes, both for individuals and society. Obese youngsters without hope of work and with a diet of cheap carbohydrates will get diabetes early and die early as a result. So what will help these people most? Building a wall and keeping them poor, obviously. more…

Richard Lehman’s journal review—14 November 2016

14 Nov, 16 | by BMJ

richard_lehmanNEJM  10 Nov 2016  Vol 375

Reinventing connected medicine

A 1300 word Viewpoint article can hardly do justice to a theme as grand as “Meaning and the Nature of Physicians’ Work”, and a lot of this piece is taken up with describing the current realities of American hospital medicine for those at its coalface. But here’s a proposal we can all identify with:”Perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another. We could work on rebuilding our practices and physical spaces to promote the sorts of human connections that can sustain us—between physicians and patients, physicians and physicians, and physicians and nurses. We could get back to the bedside with patients, families, and nurses. We could get to know our colleagues from other specialties in shared lunchrooms or meeting spaces.” It’s not rocket science. But it’s certainly how the greatest rocket scientist operated. He was Sergey Pavlovich Korolev (1907-1966), who lived and worked with his teams day and night, and put the Soviet space programme way ahead of any other while he lived. more…

Richard Lehman’s journal review—7 November 2016

7 Nov, 16 | by BMJ

richard_lehmanNEJM  3 Nov 2016  Vol 375
Tolerating uncertainty
“At once it struck me what quality went to form a Man of Achievement . . . when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.” John Keats, December 1817

This quotation heads a wonderful short essay by Arabella Simpkin and Richard Schwartzstein about uncertainty in medicine. The year 1817 marked the point at which the young John Keats decided to leave medicine and take up poetry, and the “Man of Achievement” he was thinking of was almost certainly Shakespeare. The defining characteristic of Shakespeare (and of Keats in his finest works) is of being taken beyond the circumference of the individual mind to a place where feelings and words have no outer bound. Then Keats coughed up blood, and he knew he was going to die. A few years later, his illimitable gift was destroyed. But over the next 140 years, “irritable reaching after fact and reason” would result in a cure for tuberculosis. more…

Richard Lehman’s journal review—31 October 2016

31 Oct, 16 | by BMJ

richard_lehmanOxygen for moderate COPD

This week saw the official launch of the UK Academy of Medical Royal Colleges “Choosing Wisely” campaign, which was so successful that its website crashed. It is proving a bumper week for debunking long-accepted practices. The latest is long-term oxygen for chronic obstructive pulmonary disease with moderate desaturation. This common strategy was tested in a non-blinded randomised trial in which 738 patients at 42 centres were followed for 1 to 6 years. In the supplemental-oxygen group, patients with resting desaturation were prescribed 24-hour oxygen, and those with desaturation only during exercise were prescribed oxygen during exercise and sleep.

I think the outcome is even stronger for lack of blinding, since it means that oxygen therapy doesn’t even have a tubes-hissing-in-the-nostril placebo effect. It had no effect whatever: “the prescription of long-term supplemental oxygen did not result in a longer time to death or first hospitalization than no long-term supplemental oxygen, nor did it provide sustained benefit with regard to any of the other measured outcomes.” more…

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…

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