Richard Lehman’s journal blog, 27 April 2009

Richard Lehman

This week Richard ponders continuity of care, hibernating myocardium, and whether gluten free bread came before gluten free pasta – or the other way round.

JAMA  22/29 Apr 2009  Vol 301
“Continuity of care is a defining attribute of primary care … (it) is generally recognised to have 3 dimensions – continuity in information, continuity in management, and continuity in the patient-physician relationship.” This is the opening of an interesting study of primary care as it exists in the USA, a very different beast from primary care in the UK. British primary care doctors now seem almost ashamed to mention the idea of continuity, ever since we leapt gratefully at the chance of restricting our working hours to 52.5 out of the 168 we had formerly covered. But just because we work more bearable hours we shouldn’t forget the centrality of the principle, and look to extend it to include the kind of continuity this study is about – primary care doctors looking after their patients in hospital. This was once the norm in America, as it was in pre-NHS Britain, but it has been declining steadily there over the last 10 years. Of course it is going to need a change of attitude from both secondary and primary care to reintroduce it to Britain and to preserve it in the USA – but how else is generalism to survive? We need to work much more closely with our hospital physician colleagues rather than lose sight of our patients when they are at their illest. I look forward to a time – preferably before I am on the geriatric unit – when medical ward rounds routinely include a general practitioner. We can’t work all hours, or be everywhere at once, but continuous responsibility for patients requires that we encourage shared working and better communication.

NEJM  23 Apr 2009  Vol 360
I had two diabetic patients aged between 45 and 55 who were going into severe heart failure and seemed likely to die in the next year or two – in fact one was told she would, in accordance with survival data for diabetics in the major heart failure trials. It took several months of nagging to get these people tested for reversible ischaemia and then treated with coronary bypass surgery. “Hibernating myocardium” is not cardiological bullshit but can be the key to survival in patients like these, both of whom are living normal lives several years post-CABG. Never accept a diagnosis of “diabetic cardiomyopathy” but insist on perfusion scanning or angiography. But don’t let the cardiac surgeon tinker with the ventricular architecture itself, unless there is an aneurismal wall or something like that. This trial showed that ventricular reconstruction in patients with HF who undergo CABG does not improve outcomes over CABG alone.

Life begins when two gametes share their genetic material and create the code that makes you. It can end at a stroke when a cerebral artery occludes. Are some people born to die this way? Yes, according to this genomewide study which finds a stroke risk locus on chromosome 12p13. If you want to know more about genomewide studies – and you should, because they are here to stay – then read the excellently clear review.

Another nicely written review describes minimally invasive knee arthroplasty for osteoarthritis. So-called “minimal” invasion of the knee is shown on figure 3: you have to look hard to see any difference from the traditional incision. It’s reassuring to learn that “in both techniques, cutting jigs and anatomic landmarks are used to determine the depth and orientation of tibial and femoral bone resections”. As I near the time of life when I might need such surgery, the nearer to robotic it becomes, the safer I feel. The words I do not want to read are “much depends on careful case selection and the skill of the individual operator”.

Lancet  25 May 2009  Vol 373
Relax, you’ve got acute heart failure. This is a terrifying condition and I’m not sure I’d be in a fit state to sign a consent form for an experimental intervention if I was frothing with pulmonary oedema: I’d just want morphine and furosemide and I would probably not feel at all like relaxin. However, this multinational trial (Pre-RELAX-AHF) managed to recruit 243 patients with acute HF and systolic BP above 125 and get them to try out this peptide hormone released in pregnancy which promotes peripheral vasodilatation and renal perfusion. They were not allowed any other vasodilators or any inotropes and I’m not at all clear what immediate treatment they received within the first 16 hours, before they were randomised to relaxin or placebo. The stuff certainly worked and seems safe, but this phase IIb dose-finding study certainly doesn’t clarify the use of this hormone sufficiently to predict its place in the future management of acute HF.

There are various situations in which it would be handy to manufacture a new blood vessel, one of them being in renal haemodialysis patients whose arterio-venous fistulas are blocking up at all available sites. The new vessels were grown from the patients’ own fibroblasts in sheets around a stainless steel mandrel. Nice word, mandrel; it began by meaning “a miner’s pick (1516)” according to the OED; not to be confused with a mandrill, “the largest, most hideous, and most ferocious of the baboons, Cyanocephalus maimon or mormon, of W. Africa” (SOED,1933). Slip the fibroblastic vessel off its mandrel (not mandrill or mormon) and onto the hand of your renal patient, and you have a working fistula in 7 out of 10 cases.

If you have serious multiple trauma then you seriously want your doctors to know what is wrong with you the moment you arrive. So whoomph – through the whole body CT scanner – and there are all your damaged pieces plain to see! This was once a science fiction dream, but now it’s reality, and immediate whole-body improved survival in this survey of data from the German Trauma Society. A more serious-sounding organisation would be hard to conceive.

A long and worthy seminar on early breast cancer covers almost all its bases: it is really just a long review of every kind of breast cancer except the kind I most want to know more about – which is early intraductal carcinoma, the kind that gets picked up on mammograms. There was a distressing letter in the BMJ a few weeks ago from a woman who had undergone all sorts of unpleasant and mutilating treatment for a condition which might perhaps have regressed spontaneously. Or does it? I await another review.

For some reason the Italians have a long history of research into coeliac disease, and I believe – though don’t take my word for it – that gluten-free pasta was invented before gluten-free bread. Two Italian gastroenterologists here present another comprehensive review of a condition which is ten times commoner than we thought up to 15 years ago. It’s a great illustration of the way that diagnostic tests – first antibodies and now genotyping – can revolutionise our understanding, but can also put in doubt much conventional wisdom about a condition. It’s far from clear, for example, that forcing asymptomatic people with positive tests to avoid gluten does them any favours – and most of them give up the diet anyway. But the thing I always look for in a paper of this kind is a reference to Hin et al, BMJ 1999, because I urged this primary care case-finding study on Harold with the words “do this and everyone who writes about coeliac disease in the future will cite Hin et al.”  Well, ten years on and they still are: it’s reference 90 in this article and it was also cited in the Arch Intern Med systematic review I mentioned last week. If Harold Hin had decided to become an academic, instead of using his wisdom and energy to manage my practice with kindly efficiency, the research literature of primary care would be so much the richer.

BMJ   25 Apr 2009  Vol 338
People with a tender spot over the greater trochanter are traditionally said to have trochanteric bursitis, but there is scant evidence that this condition really exists – see the editorial accompanying a randomised controlled trial. I have given hundreds of steroid injections at such points and find that they give relief in about half of the patients – the same as in this trial. Exposing people to radiation in the form of fluoroscopic guidance will result in more steroid reaching the synovial fold over the greater trochanter, but will make no difference to the rate of success. Steroid injections make people feel better, and the lateral thigh is a convenient spot for injecting triamcinolone. This will prevent hay fever, amongst other things. Often it relieves lateral thigh pain as well. Or shoulder pain, as we learnt the other week.

I’m not sure by what criteria the BMJ decides which papers to print in compressed form as a pico research article, as opposed to the full Monty, but this one on high dose inhaled steroid for wheeze following respiratory syncytial virus is certainly worth looking up in full on the website if you deal with such children – as we GPs do all winter long – and are tempted to use this treatment in the hope of reducing airways inflammation. Because it doesn’t work: in fact nothing works. This is a damned elusive pimpernel.

This article reviews all the evidence we have about clopidogrel in acute coronary syndromes. It does not, however, discuss in detail the recent evidence that clopidogrel doesn’t get converted into its active metabolite in about a third of the population. So much work for nothing, if prasugrel replaces this drug completely in the near future, as I think is likely.

I don’t write many papers myself, but comfort myself with the thought that I am sometimes the cause of papers from others. The study which gave rise to this article on diagnostic strategies used in primary care was carried out by Carl Heneghan et al without any prompting from me, but it did coincide with my urging the BMJ to run a whole series on primary care diagnosis, mapped out by Kevin Barraclough. I found myself without time to remain part of the series team, but here are the first results, which I urge you, with all due partiality, to read, mark, learn and inwardly digest. The diagnostic methods discussed here are those actually observed to be used in real primary care. The point is not so much that they are original to this paper – though some are – but that this is the first time they have been studied and discussed in this way, and illustrated with a large series of examples, of which the first is excluding serious illness in feverish children (p.1006).

Ann Intern Med  April 2009
I couldn’t find much of interest in the printed journal this week, but I will break my usual rule and point you to the Annals website for an early release article.
“Glycemic control in type 2 diabetes: time for an evidence-based about-face?”, by two US authors, presents exactly the same argument that Harlan Krumholz and I made in our BMJ editorial last week. We have decided not to add to the responses, which reach top numbers for a second week. This article does the job for us, in more detail than we had space for, with excellent summaries of all the available evidence proving that reduction of glycated haemoglobin below 7.5 in established type 2 diabetes is a misdirected effort.

Plant of the Week: Dicentra formosa “Langtrees White”

The dicentras are great friends for the neglectful gardener, growing well in most situations without any attention, and forming good clumps of pretty cut greyish foliage with flowers of pink or white over a long period. This one holds its flowers relatively high whereas the two other whites, Dicentra cucullaria and D. eximea “Alba” have purer white flowers closer to the leaves. The plants are easily split, so a friend with one will probably oblige you with a bit if you indulge in persuasive admiration.

The showy sister of these plants is the Bleeding Heart, of which enough said. If you must have a showy dicentra, try and find D. macrantha, a Chinese plant with hanging pale yellow flowers of a very odd and intriguing shape. Not for my garden, as it “needs shelter from any wind, and from late frost, and a moist  leafy and sandy soil, with protection from slugs.”