What do you say when giving a talk at a university where you once worked?  To speak about publishing, research, and the BMJ would be quite straightforward. It was a privilege to be invited and great to catch up with old friends but, did I have any additional messages for those setting out on a research career?

When you have to look your old colleagues in the eye, there is no hiding place. Its easy to be an expert from abroad but these folk knew me well. It had to be good but grounded, encouraging but realistic, inspirational yet sensible. This is how I finished: more…

JAMA  10 Oct 2012  Vol 308
1433   A Viewpoint piece by three Dutch radiologists explores the possible added benefits that could arise if developed countries introduced lung cancer screening using computed tomography (CT) in high risk groups. You will remember that the National Lung Screening Trial (NLST) demonstrated a reduction in lung cancer–specific mortality of more than 20% and overall mortality of 7%. Even hardened sceptics like me can accept the possible benefit of this form of screening. The worry is that you will find stuff you were not looking for, a subject dealt with beautifully in Overdiagnosed by Welch, Schwartz and Woloshin. You go along for your CT and you’re told that the good news is that you don’t have lung cancer. But, sorry, the less good news is that there seems to be a bit of calcium in your coronary arteries, there’s a bit of emphysema in both your lungs, your thoracic aorta is at the upper limit for width and your thoracic spine looks a bit osteopenic. All because you are (or have been) a heavy smoker. So what you now need is a proper coronary calcium score, a further look at your lungs, regular ultrasound of your aorta, and some further bone scanning. You can see how this might have added benefits for radiologists. But for health systems wanting to make the population healthier and save costs there is just one way forward: ban the sale of tobacco and provide free nicotine substitutes for any who need them. more…

JAMA  3 Oct 2012  Vol 308
1333    Can vitamin D prevent the common cold? The answer is almost certainly yes, depending on baseline levels. If you run a trial in a place where the sun shines, good dairy products are abundant, and the ocean teems with oily fish, you might get a negative result. Such a paradise exists in the form of New Zealand, where this trial was done, and it was indeed negative for a monthly dose of 100,000 units. On the other hand, trials of supplementation in places where vitamin D deficiency is rife, such as Mongolia and Afghanistan, have shown a protective effect against colds, and also more serious infections. To inform practice in the United Kingdom, we need to set up a study in a region where the weather is bad and the diet is deplorable. There are just four countries to choose from.
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Arch Intern Med  24 Sep 2012  Vol 172

Of Exercise I sing, and that benignant sweat
Which from six thousand diabetic brows
Exudes. My pen, Hygeia, speed! To save
That honey-urined tribe from mortal pains
Which Indolence doth breed, and glut of food:
That to the treadmill they may go, or healthful jog,
Or bicycle with ever-turning wheel;
These strivings, Muse, assist me to exhort,
That to the height of this great Argument
I may assert eternal Exercise:
For sloth in diabetes hastens death.

I beg your pardon: I was just trying to think of an EPIC way to convey the message of this paper about the mortality benefit of exercise in a cohort of 5859 diabetic individuals followed up from 1992 onwards in the European Prospective Investigation Into Cancer and Nutrition (aka EPIC). I know there’s confounding and reverse causality to be considered, but the burden of all such studies is always the same: even small amounts of regular exercise buy large amounts of added life. more…

JAMA  19 Sep 2012  Vol 308
1122    This week’s JAMA is devoted to obesity. It’s a bit like global warming: we can see it happening around us, we can foresee terrible consequences, we pretend to ourselves we’re doing something about it, but we know that in the end only drastic solutions will work, and these are quite likely to have unforeseen consequences. The drastic cure for obesity is bariatric surgery, but scaling this up to meet demand is something no health system has dared do to date. In fact the consequences of bariatric surgery are now well known, and for most individuals they are overwhelmingly beneficial, as this 6 year follow-up study of gastric bypass surgery shows. A cohort of mainly female subjects with BMI>35 who had Roux-en-Y gastric bypass (RYGB) surgery is compared with two control groups: a group who sought surgery but did not get it, and a control group of weight-matched individuals who did not seek surgery. The differences are startling, though hard to pick out of the abstract. Two thirds of the RYGB cohort who were already diabetic ceased to be so, and the incidence of diabetes in the rest was reduced ninefold. Systolic BP fell by more than 5mmHg in the surgical group but rose in the controls, and a similar pattern was seen with cholesterol. As for weight itself, that dropped by a fifth and stayed down more…

The top ten publications of the last year in sport and exercise medicine? It is inevitably, a personal choice and I selected these papers because they challenge, educate, and question current practice.

Some papers—great papers—that didn’t quite make my top ten: Sudden deaths among competitors in big city marathons always prompt media soul searching. It is reassuring, therefore, that a paper in the New England Journal of Medicine found the incidence rate of cardiac arrest to be 0.54 per 100,000 participants. I enjoyed another paper in a later issue of the same journal showing that Tai Chi (which in his blog Richard Lehman compares to slow disco dancing) helps patients with Parkinson’s Disease. I am interested in the application of the principles of sport and exercise medicine into mainstream medicine and found a meta analysis in Circulation:Heart Failure showing that testosterone supplementation might improve functional capacity in heart failure patients particularly intriguing. more…

JAMA  12 Sep 2012  Vol 308
981    “Considering the cost, invasiveness, inpatient requirement, and morbidity of bariatric surgery, a truly intensive nonsurgical comparison group is not only justifiable but also necessary to avoid scientific bias. A suitably intensive lifestyle intervention should include multiple components, such as residential treatment for several weeks to initiate rapid weight loss under medical supervision and development of a personalised treatment plan; home-based treatment for several months, with provision of prepared meals consistent with dietary goals, weekly sessions with a nutritionist and personal trainer, behavioural counseling, cooking classes, and membership to a sports or fitness club; and follow-up for several years, involving monthly sessions with nutrition and behavioral experts, group classes, and Internet and social media support. The financial costs of such an intervention would likely not exceed those of bariatric surgery.” This welter of wild surmise comes in the middle of a piece called surgical vs lifestyle treatment for type 2 diabetes. One of the authors is a deputy editor of JAMA, and the others work at the New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital. It may be “necessary to avoid scientific bias” but I’ve never seen it done quite so comprehensively.
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JAMA  5 Sep 2012  Vol 308
869    Cancer, multiple sclerosis, stroke: do you want your patients to get the benefit of new drugs for these conditions as soon as possible? It’s pretty hard to say no to a question like that, but if you follow the flow of this rhetoric you can easily ignore poor evidence of benefit, and absence of evidence of safety. That’s what the authors of this short piece demonstrate in relation to vandetanib for medullary thyroid cancer, fingolimod for MS, and dabigatran for stroke prevention in AF. For all these drugs, the US Food and Drug Administration used its expedited approval program, as it did for 46% of the new drugs which came before it in 2011. All of them are expensive and in each of these three cases there are clear signals of harm: but they have been let loose on patients simply on condition that there will be post-marketing studies. The same happens in the UK, and we are about to lose what small protection NICE once offered, since now any manufacturer will be able to appeal against rejection and have a NICE decision overturned by an “independent” assessor picked by the Department of Health. This ridiculous travesty of proper regulation shows that nothing has been learnt from the lessons of Vioxx or Avandia. Pre-order your copy of Ben Goldacre’s Bad Pharma now.
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Arch Intern Med  25 June 2012  Vol 172
909   The Archives are about to mutate into JAMA Internal Medicine, but I generally find them a better read than JAMA proper. One reason is the abundance of lively comment—and in the case of this paper on sex differences in the protective effect of statins, I find the comment more believable than the paper. This is a meta-analysis of eleven double-blinded RCTs of statin therapy for the prevention of recurrent cardiovascular events, and purports to show that although statins are as good at preventing recurrent cardiac events in women as in men, they do not prevent stroke or reduce all-cause mortality in women. Two British luminaries contest this, arguing that the literature search was incomplete and that the meta-analysis does not include a number of key studies which show that the protective effect of statins in women and men is remarkably similar in every category. more…

JAMA  27 June 2012  Vol 307
2595   Of all the things that made me glad to retire from general practice two years ago, pay for performance must top the list. Here’s a Viewpoint piece from the USA which explains why: “Focusing on specific outcomes does not reward skills or result in managing complexity, solving problems, or creativity. Indeed, Pink suggests such reward systems will undermine these desirable attributes.” Good old Pink: I like the cut of his jib. “Translating the ideas of Trisolini and Pink into a clinical medicine context leads to several recommendations: pay physicians a rewarding yet reasonable salary rather than piecework rewards, provide a direct ability to influence patient outcomes, and offer a continual sense of accomplishment and recognition. These would represent a more effective approach to motivating performance than specifically paying for production functions.” Good old Trisolini, too: nice jib. And here is the last paragraph of this excellent piece by Christine Cassell and Sachin Jain: “Efforts to assess physician performance are here to stay. The current system of care has invested a great deal in these measures, both financially and intellectually, and the goals they seek to achieve are critical to a high-functioning healthcare system. To reach sustainable quality goals, however, close attention must be given to whether and how these initiatives motivate physicians and not turn physicians into pawns working only toward specific measurable outcomes, losing the complex problem-solving and diagnostic capabilities essential to their role in quality of patient care, and diminish their sense of professional responsibility by making it a market commodity. Rewards should reinforce, not undermine, intrinsic motivation to pursue needed improvement in health system quality.” Amen. more…