JAMA 17 Jan 2007

Even when it is localised and resectable, cancer of the pancreas is almost always lethal. This German trial of post-operative gemcitabine has been going on since 1998 and has proved that this type of chemotherapy prolongs disease-free survival by a worthwhile amount, though in the final analysis patients given the treatment survived a median 22 months compared with 20.5 months for the control group. This is not a disease we are within sight of conquering.

Here’s an analysis of observational studies in the presence of treatment selection bias – a real brain-teaser for those who want to tell the difference between damned lies and statistics. It looks at studies of invasive management of myocardial infarction, one of the hottest topics in health service planning. The observational mortality benefit is about 50%, but use of appropriate statistical adjustment can bring that down to about 16%, in line with the randomised trials. Ah, but which adjustments really are appropriate? Whatever you do, don’t ask me. Even the accompanying editorial is pretty woolly.

286 In the UK, GPs know from personal experience as well as population studies that patients from South Asia (India, Pakistan and Bangladesh) tend to get myocardial infarction more frequently and earlier in life. This analysis of the INTERHEART study looks at native populations and shows that this also happens in the home countries. It is not a Western lifestyle effect. Surprisingly, in these countries indices of exercise and fresh vegetable intake are very poor, and the standard risk factors are also worse, including the apolipoprotein ratio, which is more predictive than other lipid measures.

People who are dying often feel immense fatigue, for a variety of reasons which are well discussed in this paper. I’ve often wanted to give them something amphetamine-like, but such drugs don’t have any proven benefit, whereas in the case discussed here, megestrol worked quite well.

The role of litigation in defining drug risks is an interesting topic, but I didn’t glean much from this essay except that litigation is a very blunt instrument. The fear of litigation has probably disposed of many more drugs than have actually appeared in court cases. Even Jesus, who was not often given to dispensing worldly wisdom, is reported as advising out-of-court settlement in case you get stung for your uttermost farthing (Matt 5;26).