Richard Lehman’s journal review – 14 February 2011

Richard LehmanJAMA  9 Feb 2011  Vol 305
569   If I were a woman, the things I would most fear from breast cancer surgery would be arm lymphoedema and recurrence of the cancer. Does one have to be balanced against the other? Common sense would suggest that the more axillary lymph nodes you dissect, the less likely it is that the cancer will recur. But last week we learned that micrometastases in the lymph nodes show very little correlation with survival, and this week we learn from this study that in women with invasive breast cancer and sentinel node metastases, survival is the same whether axillary node dissection is performed or not. The risk of arm lymphoedema goes down from 75% to 25%. So this trial continues the trend to less mutilating surgery for breast cancer begun by Sir Geoffrey Keynes in the 1920s, as I keep reminding readers in the hope that they will secure for themselves a second-hand copy of his autobiography. In The Gates of Memory, Keynes invites Henry James to Edwardian Cambridge, collects Blake manuscripts, grabs casualties under shellfire, pioneers blood transfusion, revolutionises breast cancer management, goes to the ballet, organises surgical services for the wartime RAF, cures myasthenia gravis with thymectomy, has medical students dig him a swimming pool and is criticised for his lapses in seventeenth century bibliography.

585   Last week we learned that elevation of cardiac troponins happens in up to 30% of percutaneous coronary procedures, but seems to have little prognostic importance. This week a study looks at enzyme elevations in coronary artery bypass surgery and comes to a less reassuring conclusion. The main end-point is 30-day mortality and this shows a strong correlation with increasing levels of creatine kinase. Surprisingly, perhaps, the correlation with levels of troponin-1 is much weaker.

592   Live kidney donation is a unique and usually altruistic act. Although we are fairly symmetrical creatures, we don’t have a spare twin of any other vital organ to offer to our loved ones. And the happy conclusion of this case-based clinical review is that those who make this sacrifice are very unlikely to come to any harm from it: apparently life expectancy is the same whether you have two kidneys or one. If you are ever in the position of having to advise anyone on this subject, this is the place to turn.

NEJM  10 Feb 2011  Vol 364
501   If you happen to have a neuroendocrine pancreatic tumour, you are entitled to think yourself unlucky: the incidence is about 1.8 per million women and 2.6 per million men per annum, and the prevalence is similar, as most people die within a year of diagnosis. But this week’s New England journal brings a couple of glimmers of hope: oral sunitinib produced an improvement in progression-free survival from 5.5 months to 11.4 months before this trial was discontinued early.

514   While in a second trial, everolimus improved progression-free survival from 4.6 months to 11 months. So the two drugs are much of a muchness in terms of anti-tumour effect, and it seems that clinical choice for the time being will be determined by their potential for adverse effects – which is also roughly similar.

524    If you went online in search of genome profiling, it would cost you between $400 and $2,000 to get tested for 500,000 DNA base variants, giving you some idea of your genetic risk of between 20 and 40 common polygenic diseases. This study looked at the psychological and behavioural consequences of direct-to-consumer genomic profiling. The subjects themselves chose to be tested at a discounted rate, and any counselling came at their request from the company advertising the service online, Navigenics Health Compass. Genomic profiling had absolutely no short-term effect on the behaviour or anxiety levels of those taking part.

535   It was 1969, or am I dreaming? The Labour Government then was intent on abolishing private schools and nationalising the pharmaceutical industry. We came that close to reforming our class-ridden society and saving the NHS tens of billions in subsequent expenditure. But what, you cry, would have happened to therapeutic innovation – the reason we love and cherish our pharma companies and encourage them to operate on profit margins that would shame bankers? This study from the USA on the role of public sector research in the discovery of drugs and vaccines shows that publicly funded academic research may be a far more fruitful source of therapeutic innovation than we ever realised. This includes virtually all new vaccines over the last 25 years, and dozens of new agents for cancer and infectious diseases. What our health system needs is a good dose of socialism.

Lancet  12 Feb 2011  Vol 377
Just look at the history of royal families anywhere in the world, from the beginning of recorded history, and you realise that humans in prosperity are bred to become fat cowards with a penchant for sex. Now that half the world’s population can live in conditions that ancient kings would have envied, we are all getting fatter, more anxious, and mating faster than our planet can sustain. This week’s Lancet indulges in one of its lordly series of global surveys, taking stock of body mass index, systolic blood pressure and serum cholesterol throughout the world since 1980. Richard Horton takes the opportunity for an orotund opening editorial ending with the word “unconscionable.” Plonk. Sonia Anand and Salim Yusuf are allowed four pages of commentary to meditate on “Stemming the global tsunami of cardiovascular disease.”  The authors of the papers themselves have been allowed to make up missing data by a system of Bayesian hierarchical models. These surveys done by the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group show that people all over the world are getting fatter, though not by very much; SBP is falling, especially in rich countries, for reasons we don’t understand; and serum total cholesterol has stayed much the same, except in rich countries, where again it is going down. To ignore this might be unconscionable, perhaps, but it’s hardly a tsunami: which is just as well, since tsunamis by definition cannot be stemmed.
BMJ  12 Feb 2011 Vol 342
371   A couple of weeks ago, the NEJM published a remarkable opinion piece suggesting that out-of-hospital cardiopulmonary resuscitation using chest compression lacks any evidence base and is in need of a randomised controlled trial. One respondent on doc2doc suggested that this was a bit like the suggestion in a Christmas issue of the BMJ for an RCT of jumping from a plane with or without a parachute. Not so: we know the results of that from the invariable observation of splats on the ground versus intact people under billowy silk umbrellas, whereas since CPR was devised 40 years ago, nobody has dared leave any pulseless patient without it. Maybe one in ten really has a pulse or will get one back anyway, and the rest will die, as they do following CPR. This study is consistent with the hypothesis of a useless procedure – it shows that if you improve the quality of CPR by real-time feedback, you do not improve patient outcomes.

372   To the end of my days in general practice, I used a mercury sphygmomanometer fitted with a large adult cuff as my default method of measuring office blood pressure. After several years of backing this up with ambulatory BP monitoring before starting people on lifelong treatment, I moved towards encouraging home BP measurement, though I’ve never been very happy with the quality of most electronic sphygmomanometers on sale to the public (see British Hypertension Society website). These issues are very well summarised in the editorial (provocatively subtitled “Must be done carefully, or not at all”), in response to this groundbreaking Canadian study of conventional versus automated BP measurement in primary care patients with systolic hypertension. The new “gold standard” – if there is such a thing – for BP measurement in primary care may be the use of BpTRU device in a room uninhabited by scary health professionals of any kind. The device automatically takes the BP at preset intervals and calculates the average of five readings. These are usually significantly lower than doctor measurements and correlate well with home measurements. I suspect that for most practices, the barrier will be finding a quiet room rather than buying a BpTRU machine.

Plant of the Week: Abeliophyllum distichum

February is usually such a pointless month all round, and for the gardener just a tedious marking of time until the season really starts in March. But this year a long spell of mild weather in England has seen a sudden sprouting from the ground and the opening of dead-looking buds on early-flowering shrubs. Amongst the best of these is this abeliophyllum, which is not seen as often as it deserves to be, despite my frequent allusions to its existence in these columns.

Until last week, I thought it might well have died in the hard frosts of the earlier winter, but then all the dead-looking brown froth on its tangled branches started to show signs of expansion. This froth has become a mass of flower-buds and now every branch is thickly laden with white flowers, smelling of honey and jam. Remember this later in the year, when the plant has become just a tously heap of leaves, and do not grudge it a good position by a wall near to a door, where you can enjoy its late winter scent.