Richard Lehman’s journal review – 17 January 2011

Richard Lehman

JAMA  12 Jan 2011  Vol 305
151   “Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence: A Randomized Controlled Trial.” As so often with titles like this, you have to explore the text before you can tell what the study is really about. In the UK, “behavioural therapy” usually means brief CBT and prostatectomy usually means a limited transurethral operation. Not so in the USA, where radical prostatectomy has been the urologists’ treatment of choice for localised prostate cancer over many years, leaving 65% of men incontinent of urine five years later. The “behavioral therapy” here was an intensive 8 week course on pelvic anatomy and exercises to improve pelvic floor strength and bladder control. This was highly effective, leading to a 55% reduction in incontinence episodes. Biofeedback and pelvic floor electric stimulation added nothing to this, except perhaps a warm tingly feeling in the privates.

167  Single combat between mounted Mongolian warlords, and arguments between cardiac surgeons –  these are spectator sports which it is best not to stand too close to. In my part of the world, for example, it is an article of faith that in coronary bypass operations, radial artery grafts always outperform saphenous vein grafts. I would not dare to suggest otherwise on my own, but here is a study with 36 authors to show that there is no difference in patency at one year. Gentlemen, get down from your horses, please: some of these guys are Texans.

175   We need to know more about the effect of the drugs we use for heart failure in the general mix of patients we treat in the community. The randomised controlled trials tell us a lot about specific drugs, usually when added to standard treatments in selected populations, but this may be an area where observational studies done on typical populations are just as valuable. That said, certainty is never going to be on offer, given the difficulties of defining the diagnosis and the impossibility of eliminating confounders: there is no such thing as heart failure without co-morbidity. So two cheers for this Swedish population database study which tried, but did not altogether succeed, in matching two groups of heart failure patients who took losartan or candesartan, and tracking their mortality over five years. Those taking candesartan showed better survival. It would be nice to do a similar comparison using the UK GP Research Database, but they have just made that harder by withdrawing free access.

NEJM  13 Jan 2011  Vol 364
105   The last time I wrote about acute otitis media in children I confessed shamefacedly that I still generally prescribed antibiotics, partly for lack of the lidocaine drops which an Australian study proved were effective for symptom relief (Bolt P, Barnett P, Babl FE, Sharwood LN. Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial. Arch Dis Child. 2008;93:40–44). For two decades, Calvinists from Scotland, Switzerland and the Netherlands have belaboured us on the sinfulness of treating this painful but generally self-limiting condition with antimicrobials; but those of us with weaker characters still needed something to offer desperate parents in place of the analgesics which they had already tried. And besides, their studies were generally not very good. Now along come two really good randomised controlled trials which show that co-amoxiclav reduces symptoms and improves resolution of OM – especially the latter, by otoscopic criteria. This first one was done in babies and toddlers in Pittsburgh.

116   A very similar trial was also carried out in Turku, Finland, with the same intervention (amoxicillin-clavulanate) and results which seem more emphatic because expressed as “treatment failure” – 18.6% in the active group and 44.9% in the placebo group. The editorial on p.168, “Is Acute Otitis Media a Treatable Disease?” gives a lively historical overview which in essence validates what most of us have been doing anyway.

Lancet  15 Jan 2011  Vol 377
219   When I was taught obstetrics in the early 1970s, the only treatment for pre-eclampsia was delivery of the baby. Today, the only treatment for pre-eclampsia remains delivery of the baby. The advance represented by the PIERS study is simply a better predictive model to help you decide when to put up the oxytocin drip. The criteria are maternal age, chest pain or dyspnoea, oxygen saturation, platelet count, creatinine and transaminase levels. These won’t come as a great surprise, but at least full PIERS has generated a model with an area under the curve of 0.88 for maternal harm within 48 hours.

BMJ 15 Jan 2011  Vol 342
154   Then there is the problem of how we use the knowledge that we do have. When it finally emerged that rofecoxib was associated with a nearly fourfold increase in cardiovascular events, long after its manufacturers were aware of the fact, Vioxx was withdrawn. But at the same time it became clear that diclofenac is associated with a very similar risk, yet the response has been to make diclofenac available for over-the-counter sale, and it remains one of Britain’s most frequently prescribed drugs. Prescribing diclofenac carries a higher risk for cardiovascular death than prescribing cigarettes, as this network meta-analysis confirms. But there are puzzling aspects to the data. For example, diclofenac does not increase myocardial infarction; it increases stroke with a rate ratio of 2.86, and yet the overall increase in cardiovascular death is 3.98 (with very wide confidence intervals). What are the other causes of CV death here? Heart failure is the obvious one, since the more effective the NSAID, the better it kills heart failure patients. We need our few surviving clinical pharmacologists to work on the GPRD and give us some clearer answers. In the meantime, all prescribed and over-the-counter diclofenac should carry a health warning: “Regular use of this medication quadruples your risk of a serious stomach bleed and death from cardiovascular disease.”

Arch Intern Med  10 Jan 2011  Vol 171
68    A nice study from Rochester General Hospital (NY) show that it is perfectly possible to reduce postoperative meticillin-resistant Staphylococcus aureus infections by 93% – while reducing other wound infections at the same time. The intervention was pretty hefty, however: they screened all patients listed for cardiac surgery for MRSA and gave intravenous vancomycin to those carrying it; they gave intranasal mupirocin to everyone for 5 days before surgery; and used mupirocin ointment at the site of removed chest drains.

73   A recent visit to Yale left me dizzy with the pleasure of talking to some wonderful people about that most tricky of subjects – clinical decision-making under uncertainty. I wish this paper had appeared before my visit, so that I could have met the authors. Their conclusion is:” The experiences of practicing clinicians suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions. To improve decision making, they need more data, alternative guidelines, approaches to reconciling their own and their patients’ priorities, the support of their subspecialist colleagues, and an altered reimbursement system.” Fortunately I did get the opportunity of warning a few of their Yale colleagues against repeating the idiocies of the UK reimbursement system, aka Quality and Outcomes Framework.

Plant of the Week: Viburnum farreri
The discoverer of this plant, Reginald Farrer, was not a modest man, but nonetheless he forebore to name it after himself: that was done by others after his death in the mountains of North Burma. He himself called it Viburnum fragrans. Quite apart from his claims on posterity as the best of garden writers ( and author of numerous completely unreadable novels), he fully deserves immortality for introducing this winter-flowering shrub to the West. Bringers of plants that shed fragrance through the British winter deserve a high place among the benefactors of humanity.
That said, it must be admitted that this is not the tidiest of garden ornaments throughout the rest of the season. Once its pink flowers have gone brown and ceased to smell of well-powdered old ladies, it becomes a straggly mass of fairly ordinary green corrugated leaf. But I would still not be without it, either in its usual guise or as the bright white-flowered variety, candidissimum.