Richard Lehman’s journal blog, 30 March 2009

Richard Lehman

We are very pleased that Richard Lehman is back with us after a break. As before, his ever popular journal blog will be published weekly.  This week, Richard gets off to a splendid start by covering a range of subjects from Greek nymphs to footstools and defecating…

JAMA  25 Mar 2009  Vol 301
The problem of pain was the subject of CS Lewis’s first attempt at popular theological argument, prompting a fellow don at Magdalen College, Oxford in 1940 to remark that “the problem of pain is quite bad enough without Lewis writing about it.” It is indeed easier to write about pain than to endure it all the time, as I’m told that Lewis acknowledges – I would look it up myself, but I fear for the safety of nearby ornaments. Every pain is different, but there are some generic aspects to chronic pain management which we tend to skimp on in primary care, and that is the issue which this US trial attempted to address. The intervention was administered by a psychologist and an “internist”, and usually involved a face-to-face assessment with specific treatment recommendations plus a 4-session workshop encouraging self-management and activity. The gains, though significant, were sadly modest at the end of 12 months for these patients with chronic musculoskeletal pain.

NEJM  26 Mar 2009  Vol 360
Oddly enough, the human foreskin carries a theological pedigree almost a long as the problem of pain, though I am not sure whether CS Lewis ever wrote on the subject. God is found commanding its removal to Abram and his household as early as Genesis Ch 17, whereupon Abram becomes Abraham; Paul, apostle of Jesus to the Gentiles, later prudently decided that God no longer demanded it, whereas Muhammad, who was made of sterner stuff, got out the knife once more for all his followers. The rather curious result is that the foreskin is regarded a sacrosanct in certain European countries, including Britain, but is routinely done away with as soon as possible in large parts of the Middle East and also – for less obvious reasons – the United States of America. Africa falls between, and of course circumcision has been in the news a lot as a possible means of containing the spread of HIV. This study examines its effect on two other sexually transmitted infections – herpes simplex virus 2 and syphilis. Such is the popularity of the procedure in Uganda that randomisation was between immediate and delayed circumcision, rather than no circumcision at all. The immediately circumcised duly showed fewer of both infections. Expect changes in African health policy that will produce bagsful of foreskins to rival those brought back from Philistia by David, who later became the legendary King of Israel (see 1 Sam 18.25).

More uncomfortable reading for male readers of the New England Journal: 38,343 annual digital rectal examinations and PSA tests in the intervention group, thousands of transrectal prostate biopsies, hundreds of radical prostatectomies and lots of radiation above the genitals. And after 7 years, the result of all this prostate screening? 50 deaths from prostate cancer in the screened group and 44 in the control group. This was – and still is, since it is only half-complete – the US trial called PLCO, where the PSA cut-off for biopsy was 4.0. Treatment data are not given, and the study goes on: it has not been stopped for futility. But it’s not looking good.

The study called ERSPC by contrast is really a series of linked trials in European countries with differing recruitment and randomisation procedures and a PSA cut-off of 3.0 in every country except Finland. At 14 years from randomisation, there was no difference in prostate cancer mortality, but at fifteen years the control group suddenly fares a lot worse (see Fig 2); and if you take the mean of about 9 years, you get a 20% difference in favour of screening. This benefit was limited to those under 70, and to prevent one death from prostate cancer you would have offer screening to 1410 men and submit 48 to surgery and/or radiotherapy. Digital rectal examination and PSA are just not good enough for the detection of the prostate cancers that matter. The trials go on, but I think the strategy is dead.

There aren’t many effective interventions for chronic obstructive pulmonary disease, but one that seems to produce real improvements in quality of life in trial settings is pulmonary rehabilitation. This article is a straightforward description of how it’s done in the USA. “The successful coordinator has excellent interpersonal skills, since (at least initially) a primary task is to motivate people to do what they find unpleasant.”  Most people with COPD show an initial benefit, but this declines after a few months. Keeping people doing things they find unpleasant is never easy.

Lancet  28 Mar 2009  Vol 373
Body mass index is one of many measurements in medicine that enjoys a popularity beyond its modest deserts, but at least we have data from lots of prospective studies which are pooled here to give an estimate of cause-specific mortality in 900,000 adults. At a BMI below 22.5, smokers die much faster and thus give all thin people a spuriously bad prognosis. If you read the Summary you will get the opposite impression due to misuse of the word “inversely”. Cardiovascular mortality tends to rise steadily with all levels of BMI, but a little middle age spread does no harm to overall prognosis provided you stay below 30. Once BMI goes over 40, you are looking at a drop of life expectancy of 8-10 years, similar to life-long smoking.

This nationwide study looked at the rate of epilepsy in every little Dane who bashed his or her head in childhood and was taken to hospital. The risk varies with severity of injury, as you’d expect: kids with skull fractures, or with impaired consciousness for less than 30 minutes, have a twofold risk of later epilepsy, while severe brain injury with unconsciousness of over 30 minutes results in a sevenfold risk.

If you have renal cell carcinoma, your only real chance of long-term survival is that somebody will chance to spot it before you have any symptoms. Even this is no guarantee: more small renal masses are being removed each year because of incidental detection on scanning, but still mortality has increased. So this seminar on the subject concentrates on two ends of the scale: the optimal management of small renal masses and the management of metastatic renal cell cancer. Here there is modest progress, much hyped in the press; bevacizumab does prolong life usefully in a significant proportion of patients.

BMJ  28 Mar 2009  Vol 338
When I became a GP, obstetrics was still a routine part of our job, though I quickly abandoned the role of accoucheur without the slightest regret. The last time I tried to stop premature labour was before that at the Middlesex hospital, where on the instruction of my senior registrar I exhausted that hospital’s entire stock of injectable ethyl alcohol. The lady in question enjoyed her intravenous treat and duly stopped contracting. This most ancient of tocolytics does not get a mention in this review of adverse reactions to drugs given to stop labour, but the beta-adrenergic drugs we used more commonly do get a bad mention here, whereas something called atosiban gets the all clear, and nifedipine lies somewhere between.

Depression scoring systems were devised and validated in research settings and then imposed on British GPs via the QOF system for every patient newly presenting with depression. Two studies of their use are presented side-by-side here; the first one finds – surprise, surprise – that doctors try to administer these things but do not base their treatment decisions on them; and the second finds that on the whole, patients don’t mind filling them in. Such is the mighty evidence base for giving doctors financial incentives to use depression questionnaires.

This article on chronic constipation in adults shows what it calls the correct position for defecation, illustrated by a pensive naked man sitting on a white lavatory with his feet supported by a footstool. A courteous American correspondent of mine, Jonathan Isbit, would half approve. Jonathan says he was inspired by my first piece in the BMJ, a Personal View called “In Praise of Hunch Backing” to back his hunch that many bowel diseases and almost all constipation are the result of modern man adopting the sitting position to defecate. Jonathan would have our knees much higher while defecating than a mere footstool can ensure. Squatting over a hole in the ground, we would prevent appendicitis by pushing our right knees into our iliac fossae and prevent colon cancer, diverticulitis and constipation by getting our rectus muscles into bowel-squeezing action. However, careful placement of the feet is necessary, so as not to give the word “footstool” a whole new meaning.

Arch Intern Med   23 Mar 2009  Vol 169
There have been dozens of trials of vitamin D supplementation for the prevention of non-vertebral fractures and if you pool them all you get equivocal results. However, if you carry out a meta-analysis by oral dosage, there’s a clear difference between trials using a low dose of vitamin D and trials using more than 400u daily. People over 65 reduce their fracture risk by at least 20% if they take a decent amount of vitamin D.

Eating large quantities of red meat is a bad thing for global resources and also a bad thing for people, according to this simple but enormous study of self-reported food intake in 500,000 Americans aged between 50 and 71. There was a 30% difference in mortality between the groups reporting the highest and the lowest red meat intake, when adjusted for a wide but possibly insufficient range of confounders. The extra deaths are from cardiovascular disease and cancer. But you can eat white meat – meaning chicken, I think – not just with impunity but with benefit.

If you are interested in hypertriglyceridaemia, then here’s some detailed epidemiology for you to revel in from 5610 people aged over 20 studied in NHaNES 1999-2004. As usual, it’s a confusing picture, especially as there was no standardisation of sampling conditions, and only rather vague associations emerge, chief of which is physical inactivity.

If you have a close relative who has had venous thromboembolism, your own chances of getting one are at least doubled, according to yet another important study of the subject from Leiden. In fact it’s usually more useful clinically to factor in a family history than to take blood for a so-called thrombophilia screen.

Having been unwisely drawn into a public argument about diabetes, I have only one hope of getting everybody to agree with me, and that is to keep saying nice things about metformin. It’s the only treatment which can actually be shown to improve outcomes in type 2 diabetes without any shadow of doubt, and every patient with this condition should be persuaded to take it unless the gastrointestinal side-effects are completely intolerable. The key to its action is probably to reduce insulin resistance, and the trial here attempts to gauge its value in type 2 diabetics who require insulin. This important fact fails to get a mention in the title of this paper, which also claims to report “long-term” effects, though the mean follow-up was 4.3 years. Over this relatively short period, patients randomised to metformin lost weight, had better glycaemic control, needed less insulin, and had fewer macrovascular adverse events. But unfortunately, as in so many diabetic trials, the investigators chose to lump all sorts of dubious “microvascular” outcomes into their primary end-point and thereby failed to reach statistical significance by dilution.

Plant of the Week: Daphne odora

Daphne, you will remember, was the nymph who eluded the amorous attentions of Apollo by turning into a tree. This was a popular subject for artists and sculptors like Bernini (see The Mirror of the Gods  Malcolm Bull, 2005) and even for the first composer of a German opera, though sadly we have lost the music which Heinrich Schütz wrote in 1627 to be sung by his tree.

Many plants were once given the name of Daphne, but for some reason Linnaeus settled the title on a genus of low shrubs, little resembling the nymphs of Thessaly except perhaps in their gorgeous perfume. Of all the daphnes, this small evergreen plant is perhaps the most ravishingly scented, though there are many competitors among her sisters and cousins. In fact it is possible, with reasonable care, to enjoy the scent of different daphnes throughout the year. Let us begin like the Iranians at Now Ruz, the spring equinox:

March-April: Daphne odora, D blagayana
April-May: D tangutica, D collina
May-June: D x burkwoodii, D cneorum
June-July: D x hybrida, D sericea
July-Oct: D x transatlantica, D x napolitana
Oct-Nov: D susannae
Nov-March: D bholua, D jezoensis, D mezereum

The trouble is that one or other of these will invariably die on you just when you most look forward to it. D odora is relatively robust, though tradition has it that the clone with yellow-edged leaves, Aureomarginata, is the only one reliably hardy in English gardens. I have just bought a handsome Japanese clone called Sakiwaka with good plain leaves and I’ll let you know how it gets on next winter.