JAMA  12 June 2013  Vol 309
2345   “Moral panic” is a term which dates back to the 1830s and describes “an intense feeling expressed in a population about an issue that appears to threaten the social order.” Just now the Chief Medical Officer for England is putting her weight behind a campaign of moral panic about antibiotic overuse by doctors, and if I dissent I shall be considered a threat to the social order. We are supposed to confess that as GPs we greatly overuse antibiotics, and as a result they are losing their effectiveness and we are about to return to the pre-antimicrobial era. The study reported here from the USA shows that primary care paediatricians can be persuaded to use fewer broad spectrum antibiotics for respiratory infections in favour of amoxicillin and penicillin V. The fact is that after 60+ years of “overuse,” these remain highly effective first-line treatments in primary care, and you don’t need most of the rest. We may differ on the likelihood of their usefulness in particular clinical contexts, but there is no room for moral panic. Dame Sally should save that for the use of antibiotics in animal feed.
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JAMA  5 June 2013  Vol 309
2223   It’s nice to see some meaty stuff in JAMA this week: I was beginning to grow despondent. It’s true that we are expected to take an interest in the Association Between the MUC5B Promoter Polymorphism and Survival in Patients With Idiopathic Pulmonary Fibrosis after this article, but first let’s rejoice in a good trial (REDUCE) with a nice clear clinical message: “In patients presenting to the emergency department with acute exacerbations of chronic obstructive pulmonary disease, 5 day treatment with systemic glucocorticoids was noninferior to 14 day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure. These findings support the use of a 5 day glucocorticoid treatment in acute exacerbations of COPD.” I know that some of my older and more sensitive readers will flinch at the use of “noninferior” and “reexacerbation”, but hey, Shakespeare invented some pretty silly words, and at least with these we get the meaning. When treating exacerbations of COPD, give the prednisolone 40mg (or prednisone over the Atlantic) for 5 days not 12.
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NEJM  30 May 2013  Vol 368
2059   Don’t read this paper, but rejoice that it exists. It’s proof that cancer genomics is the best kind of science—incomplete, dynamic, complex, and full of hope. It is also open to all who can make use of it: “We identified at least one potential driver mutation in nearly all (adult) acute myeloid leukemia samples and found that a complex interplay of genetic events contributes to AML pathogenesis in individual patients. The databases from this study are widely available to serve as a foundation for further investigations of AML pathogenesis, classification, and risk stratification.” I think I am falling in love with the Cancer Genome Atlas Research Network.
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JAMA  22 May 2013  Vol 309
2105   Viewpoints carry with them an offer of agreement or disagreement, and everything I write in these columns is based on that. I hope you sometimes click on the links, and I often wish you would disagree with me more. I hope the same goes for the authors of this Viewpoint piece about Medication Nonadherence: a Diagnosable and Treatable Medical Condition, but they sound almost angrily in earnest. “To further improve the diagnostic accuracy of the problem, attention should be paid to the underlying behavior(s) at hand. There are at least six representative medication nonadherence phenotypes, highlighting the differences in underlying behaviors and barriers that exist at the patient level…” “Each medication nonadherence phenotype requires different diagnostic tools and treatments…” The mechanistic jargon proceeds relentlessly: find out the adherential fault your patient suffers from, and take correctional action. Personally I think most “nonadherence” is due to a failure to gain the patient’s trust and understanding in the first place: perhaps we’d do better by examining some “health professional non-communication phenotypes” and correcting them with education about shared decision making.
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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…