Richard Lehman’s journal blog, 5 April 2009

Richard Lehman

From bed bugs via the Roman goddess of dawn – complete with Latin poetry – to Siberian bug bane: Richard takes us through the Big Four in his usual inimitable fashion.

JAMA  1 April 2009  Vol 301
This pragmatic trial from Seattle looked at whether it was more cost-effective to provide housing and support for homeless people with severe alcohol problems or keep them on a waiting list and let them turn up to hospitals, prisons, shelters and emergency services in the usual way. Remarkably, by providing housing for these despised individuals, they halved the costs they incurred: this study proves that it is actually cheaper to provide homes for “hopeless drunks” than to leave them to fend for themselves.

Here is a Clinical Review of Cimex lectularius, the humble blood-sucking bed bug which is seldom a vector for disease and doesn’t even cause itchy bite marks on 70% of its victims. It is nevertheless a curse to hoteliers and hard to get rid of. There is apparently a Mexican proverb which advises that “the best way to put an end to bed bugs is to set fire to the bed”. In fact there are stories and proverbs and curses associated with bed bugs from the dawn of literature, and from all parts of the world. The little beasts feature in the earliest bedroom jokes, together with copulation and farting, just as in the latest ones, as you’ll find if you compare The Clouds by Aristophanes with the many American bedbug websites. The earliest recorded name for them is sar-an which is Old Sumerian for “numerous in straw” – a rueful reference to the likelihood that five thousand years ago, your Sumerian bed would be riddled with bugs. The same applied to Arabic beds, as shown by the proverb, “a bed bug has a hundred children, and says ‘how few.'”  A Spanish proverb comforts the afflicted by saying that “you can’t have more bed bugs than a blanketful.” There is a charming story about a rich man, his beautiful wife, a bed bug and a visiting flea in the fables of Kalila and Dimna, widely circulating in India and Iran about 2,000 years ago. The innocent, hospitable bed bug gets killed for a bite inflicted by the flea. There are legendary Hopi sex stories about bed bugs. But the most remarkable bed bug story is to be found in the apocryphal Acts of John, proving that among the sober, chaste and pious early Christians there must have been some entertaining fibbers with a lively sense of humour. The apostle is trying to get a bit of kip on a straw mattress but the bed bugs are stopping him, so he orders them to leave the room in the name of God. Next morning the bed bugs are found huddling together outside the door. John allows them back inside and to bed because they have been obedient to the divine will, and says to his followers, “Be ye like the bed-bugs.”

NEJM  2 Apr 2009  Vol 360
Most of the half-million annual deaths from cervical cancer occur in countries which will never be able to afford whole-population screening using regular cervical cytology, which is partially effective but enormously expensive. This landmark study from rural India used a single test for human papillomavirus and showed a near-halving of cervical cancer deaths compared with cytological testing or visual inspection of the cervix with acetic acid. Most HPV infection is acquired soon after women become sexually active and disappears harmlessly in a few years, so the positives that are significant are those in older women: between 30 and 59 years old in this cluster randomised trial. Read the accompanying editorial to appreciate what a real breakthrough this study represents for screening policy throughout the world.

Statins are great drugs provided you take them in time, but taking them when you have organ failure may be too late. People with established heart failure get no discernible benefit and this trial (named after the Roman goddess of dawn, AURORA) shows the same for people with advanced renal failure requiring haemodialysis. Those randomised to rosuvastatin showed the expected drop in LDL-cholesterol but no improvement in outcome. The goddess did not smile on this trial, and we cannot sing

AURORA lucis rutilat
caelum laudibus intonat
mundus exultans iubilat
gemens infernus ululat,
cum ille rex fortissimus
mortis confractis viribus
pede conculcans tartara
solvit catena miseros!

Not until Easter, anyway.

The reasons why some boys and fewer girls wet their beds are somewhat obscure, but it’s probably worth following the advice of this clinical review of (nocturnal) enuresis and doing a clinical examination, urine dipstick and ultrasound to rule out constipation, infection or a structural or neurogenic cause. The treatments are the same as they’ve been for decades: an alarm device, a tricyclic antidepressant, or (with due care) desmopressin.

Lancet  4 Apr 2009  Vol 373
Just because something is associated with something else in fairly linear fashion, like LDL cholesterol and cardiovascular events, doesn’t mean that you can necessarily drive the process the other way. But with statins this does seem to happen, and the benefit seems proportionate to the LDL-C lowering, as in this analysis of the JUPITER trial in initially healthy subjects given a fixed dose (20mg) of rosuvastatin. The degree to which these people responded in terms of LDL-C lowering roughly matched the degree to which they had fewer CV events. But an even better fit was the degree to which C-reactive protein was reduced. So JUPITER provides more evidence that the anti-inflammatory effects of statins may be even more important than their lipid-lowering effects. Juppiter Optimus Maximus.

For nearly eleven years I’ve kept my eye on trials of different interventions for coronary artery disease, but if and when my turn comes to have one, I’m by no means sure which way I’d jump. If I just had angina which was well controlled with medical treatment, I shouldn’t be in any hurry for an invasive intervention at all, because COURAGE tells me that I’m unlikely to benefit. This collaborative analysis of individual patient data tells me that even if I had three-vessel coronary disease, and decided to let someone interfere, I’d do just as well with percutaneous intervention as with coronary artery bypass grafting. But these are all quite old trials, and techniques have moved on – CABG no longer uses mainly venous grafts, and PCI with balloons and bare metal stents has given way to drug-eluting stenting, though for no good reason I can discover. In a thoughtful editorial, David Taggart (p.1150) discusses these technical advances and the difficulty of giving patients an informed choice in such matters.

Novel opioid antagonists for opioid-induced bowel dysfunction have been around for some time already, but they haven’t yet surfaced in British palliative and primary care. In the case of methylnaltrexone this may soon change, because there have been convincing trials of oral administration to people with advanced illnesses, albeit involving small numbers. However, cost may be a barrier with this drug and with alvimopan, which is still being trialled mainly for post-operative ileus.

BMJ  4 Apr 2009  Vol 338
Here is a Scandinavian study which claims to show that appendicitis or mesenteric adenitis protect against subsequent ulcerative colitis, but that appendicectomy itself does not. The problem for me is that I don’t know which category I fall in. I had my appendix removed, very incompetently, when I was 9, and was later told that it was normal. But I certainly had agonising right iliac fossa pain the day before. Perhaps I had “mesenteric adenitis” but I’ll never know. If I did, then I’m protected against UC, but otherwise I’m not. Unless Scandinavian record keeping is uncommonly good, I think there may be room for a bit of doubt in the figures, though perhaps not enough to alter the conclusion of this study. I tried to work it out but was deterred by opaque Scandinavian technical prose, which becomes slightly interesting in the “possible mechanisms” section.

812    It is worth case finding for type 2 diabetes if you believe that early treatment makes a difference. I am not sure about the evidence base for this, and certainly I don’t consider that UKPDS alone suffices. Here is the validation of a risk score – the QDScore – which is based on ethnic origin, social class, immediate family history, treatment for blood pressure, known cardiovascular disease and steroid use. It predicts about half of incident type 2 DM over a ten year period. But if we were serious about this, we’d be doing 5-yearly fasting blood sugars for everyone over 50, or 40 if SE Asian or obese, and offering big exercise and diet interventions while there were still enough beta-cells to rescue.

Around the time I got appendicitis, I went to a visiting fair and paid sixpence to look at a bearded lady in a freak show. That was a lot of money to see a fat woman with too much androgen, and her plight still fills me with horror, fifty years later. Hirsutism is a blight to the body image of many women, but there is now a range of options to treat it: this short review provides good clear advice on how to use oral contraceptives, metformin, spironolactone and finasteride in various clinical scenarios. In all but severe or rapidly progressive cases investigation is unnecessary.

Plant of the Week: Cimicifuga simplex “Brunette”
Having mentioned bed bugs at such length, I feel compelled to offer Siberian bug bane as the plant for this week, though it is grown for autumn rather than for spring effect. Just now it may be pushing its first tufts of ferny leaf through the soil, unnoticed amidst the beauty of primroses, fritillaries, hepaticas and daffodils. When these fresh delights have faded, it continues to grow until its divided leaves reach up to about a metre. It doesn’t usually flower until October, when it is very welcome, especially in this bronze-leaved version with pink flushed bottle-brushes of flower. Take its dried leaves with you whenever you visit the cheaper hotels of Siberia, or indeed New York.