Richard Lehman’s journal review – 20 September 2010

Richard LehmanJAMA  15 Sep 2010  Vol 304
1173  Medical students dominate this week’s JAMA. These are American medical students, who all have degrees in something else before they start medicine, so they should be well rounded, relaxed human beings in the prime of youth, enjoying a new and interesting course of study which will result in their becoming useful and privileged members of society, able to feel altruistic while nevertheless remaining secure and well paid. 

A Confucian dream ticket: and yet this study claims that over half of them are burnt out. Before they’ve even started. And with burnout, as measured by the Maslach Burnout Inventory, comes a lowering of professional standards and contempt for altruism. This study of 2682 out of 4400 eligible students in 7 American medical schools shows that something is wrong: but is it the fault of the students or the system which subjects them to such invasive analysis at every stage of their learning? Doesn’t everyone need to lighten up a bit? The study which follows (p.1181) seems to show that in a similar cohort, 14% have definite depression. Now that’s more like the expected figure, and these are the kids who need help. The rest just need to skip lectures a bit more.

1191   In life as in medicine, context is all. You can learn this from Shakespeare, or Chinese history, or falling in love, or playing music with other people: or, it seems, from a 4-hour course on contextualisation. This study was conducted at the University of Illinois, Chicago, where fourth year students either did or didn’t attend four one hour sessions of training in thinking about the context of clinical decision-making. Those who attended did better in probing for contextual issues with simulated patients. I think this is an important paper for medical educators as they help young people to cross the chasm between deliberately simplified biomedical science and a lifetime of learning to deal with the complexity of real lives. This is, after all, the main task of medical education.

NEJM  16 Sep 2010  Vol 363
1117    It’s a trickle rather than a flood, but treatments based on genomic understanding of pathological mechanisms are beginning to show promise in several areas. For example, when a patient is diagnosed with myelofibrosis, you can’t at present do much more than commiserate and ask how they get on with the haematologist. But an orally available Janus kinase inhibitor may change all that for the 50% of patients who show mutations at the JAK2- V617F site. A drug which is at present just called INCB018424 marked symptomatic benefit and objective disease remission in a high percentage of these patients, with a 10% incidence of serious adverse effects.

1128   For drug companies wanting big profits from chronic diseases, surrogate markers are Satan’s gift, saving them the trouble of looking at real end-points and allowing them to sell billions of dollars’ worth of drugs before they are proved to be ineffective or harmful. Nobody knows this better than GlaxoSmithKline, manufacturers of rosiglitazone, who therefore funded the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study. Fortunately this is a scientifically valuable study, which won’t provide GSK with much scope for producing yet another COPD drug of dubious safety and effectiveness, but does reveal the existence of a large subset of COPD patients with accelerated disease progression – the so-called frequent-exacerbation phenotype. These people are not identified by any flashy biomarker or sophisticated lung function test, but simply, as the name implies, by how many exacerbations they can remember.

1139  Now to bonnie Scotland, where there was much dismay from sections of the public in 2006 when smoking in public places was banned. We might have expected an immediate benefit to some sections of Scottish society, such as those who smoked in pubs, and there was indeed an immediate drop in myocardial infarction. But what of the wee bairns who generally receive all their second-hand cigarette smoke at home? Well, happily enough they seem to have benefitted too: before the ban, there was a 5.2% annual increase in hospital admissions for asthma in children under 15; after the legislation there was a fall of 18.2% per year.

Lancet  18 Sep 2010  Vol 376
975   All my clinical life I waited for something to replace warfarin which would avert the need for constant monitoring and so free up an immense amount of clinical time. Sure enough, dabigatran is now with us, but I shall never get to use it, except perhaps as a patient. The RE-LY trail last year showed that it was as effective at stroke prevention in atrial fibrillation as warfarin at a standard dose, and caused fewer haemorrhagic complications. This substudy shows that the size of the relative benefit relates to the standard of INR control in the warfarin patients. If Boehringer Ingelheim were to set their price for dabigatran at the average cost of warfarin plus all the expenses of INR monitoring, it could make a handsome profit and benefit the whole world.

991  Talking of benefiting the whole world brings us on to this lengthy essay about the millennium development goals. It’s an attempt to set the global health agenda for the decade or more after 2015. It’s a wordy/worthy document of the sort that Richard Horton seems to like, and bears the superscription “The Lancet Commissions.” In retirement from clinical practice, I would like to do something for the resource-poor world, but this sort of document reminds me of Blake’s dictum: “He who would do Good must do it Minute Particulars: General Good is the plea of the Knave and the Scoundrel.” I’m trying to draw up a list of Minute Particulars to work on and maybe I’ll  let you know how I get on: if I ever do. I may just be a knave or scoundrel.

BMJ  18 Sep 2010  Vol 341
  This meta-analysis of screening for prostate cancer has Mia Djulbegovic, student, as main author: further down the list comes Benjamin Djulbegovic, professor of urology. I wonder if they are related. Anyway, Mia’s meta-analysis of the randomised screening trials tells us what most of us already knew, but which remains heresy in some American circles: that prostate specific antigen is a lousy screening test, liable to increase diagnosis without any demonstrable benefit in mortality and at a heavy cost in adverse effects from intervention.

594   So the rational thing is to have nothing to do with PSA as a screening test. Now I am fairly rational, but also 60 and mildly troubled with occasional urinary symptoms, and this Swedish registry study confirms what others have already found: that if a chap of 60 has a PSA of 1 or less, his chances of dying from prostate cancer are effectively nil. So should I just sneak along and have a PSA, in the hope that I am in the under-1 category and can therefore tick that off my list of likely modes of death? But then again, what if it’s 4? Do I want lots of further blood tests and perhaps a transrectal biopsy, and horrible treatments for a cancer that may never have manifested itself in my remaining lifetime? We’re supposed to share these decisions with our patients, but I’m no good at sharing them with myself.

595  And now for another miserable, all-too-familiar screening dilemma: a not-very-reliable test for a condition which carries some added risk of an increasingly common cancer. In this case it’s Barrett’s oesophagus, which in a few cases turns into oesophageal cancer. This could be called the British cancer, since rates here are higher than anywhere else, particularly in Scotland. But there are millions of people with Barrett’s oesophagus and their absolute risk of getting cancer is small. Swallowing a Cytosponge might make population screening for Barrett’s possible, but what would ensue? Millions of regular endoscopies with treatments which still haven’t been precisely defined. I don’t want to get cancer in my oesophagus, but I don’t like the sound of this. There’s an excellent clinical review of Barrett’s on p.597, but as before, I’m left wishing that he had never invented his oesophagus.

Arch Int Med  13 Sep 2010  Vol 170
   This editorial entitled: Long term opioid treatment of nonmalignant pain: a believer loses his faith, is the best thing in this week’s Archives: well worth getting your local medical librarian to send you the PDF. Mitchell Katz is a clearly a highly experienced and compassionate doctor, who has dealt with people in all sorts of pain, physical and otherwise. He has gone down the path we all have – or rather gone up the analgesic ladder we all have. Add some codeine to the paracetamol. It’s not working as it should: add some more, or move to tramadol. Set limits. Patient breaks limits. Try buprenorphine: and so on. When I retired from my practice a few months ago, I left my partners about ten such chronic-opioid-for-chronic-pain patients to take over. When I returned for a few locum sessions, I looked to see what was happening to them. Much the same thing. I don’t know what the solution is.

1425   The paper about fatal and non-fatal emergency room visits and adverse drug reactions which provoked Mitchell Katz’s editorial. These are increasing in line with increased opioid prescription for chronic pain.

1433   Sometimes puns are so bleeding obvious that you can’t avoid using them. As with this study, which shows that when you add aspirin or clopidogrel to warfarin for atrial fibrillation you cause more major bleeds, and if you combine all three – well, you get even more.

1450   In the editorial about rosiglitazone last week, I mentioned in passing that we accept pretty high levels of cardiac risk from commonly prescribed non-steroidal anti-inflammatory drugs. I wasn’t condoning that, and I think this is something that needs a lot more attention. The risk is threefold: many NSAIDs other than naproxen and perhaps ibuprofen increase the risk of myocardial infarction; all NSAIDs increase the risk of heart failure; and this paper reminds us that NSAIDs as a group increase the risk of atrial fibrillation. This is independent of the association with HF and increases with use for over a year.

1456   About 20 years ago, a patient of mine returned from the USA with an inferior vena cava filter, inserted after one or more deep vein thromboses. I dimly remembered learning about this procedure in medical school and muttered in my head, or perhaps aloud, “Oh yes, that’s the kind of thing they get up to over there.” And yes, they’re still getting up to it, far more they should be even by American guidelines. Conversely, in the UK, we may be doing too few: I’ve in fact never come across a patient who has ever had one done in Britain. These tribal differences in medical practice have hardly been dented by the arrival of Evidence-Based Medicine. “Driven by patient expectation and physician preference” is a polite way of putting it: it’s the reason that leeches stayed popular for so long.

Plant of the Week: Geranium “Salome

A few hardy geraniums remain pluckily in flower until the very end of the season, and so deserve to be in every garden. This is one of them – “Buxton’s Blue” is another. Salome may have got her name by having a black heart surrounded by the purple of wine, or perhaps gore from the Baptist’s head. She dances in the autumn light and is worth half of Herod’s kingdom.