Richard Lehman’s journal review, 21 February 2011

Richard LehmanJAMA  16 Feb 2011  Vol 305
I like to hold a torch for JAMA, and once even suggested to the BMJ that it should try to become more like this decently old-fashioned American weekly, provoking dismay and perhaps even derision from my progressive friends there. Anyway, the BMJ has gone its own way, and JAMA has stayed the same, arty covers, bad poems and all. Its only fault from the British point of view is that it can occasionally become too fixated on outcomes research which relates purely to the American health system, as is the case this week. So I am left with just one short Commentary piece to comment on, called Sudden Acceleration of Diabetes Quality Measures. It’s very much on the lines of the editorial I wrote with Harlan Krumholz about QOF for diabetes in the BMJ two years ago, so naturally I wholeheartedly approve. In relation to HbA1c targets, the authors write, “There was no effort to ascertain patient preferences or measure harms, and the virtuous circle of measurement for improvement was replaced by a vicious circle of measurement for compliance.”

NEJM  17 Feb 2011  Vol 364
638   Speaking of politicians and medical authority figures distorting the available evidence brings us nicely on to the question of our response to H1N1 pandemic influenza. With hindsight, we know this was a benign pandemic with a lower overall mortality than seasonal influenza. But the initial mortality figures from Mexico were terrifying, and among the first to die in the UK were some pregnant women and children. The political imperative to Do Something was swiftly answered in the Chief Medical Officer’s measures for isolation of cases and the widespread deployment of antiviral drugs: futile at best, and probably harmful because anyone with a potentially serious febrile illness was told to keep away from health professionals. Still, you had to sympathise with the CMO. What we all longed for was an effective vaccine, and as soon as this arrived it was widely deployed, although nobody knew much about it except that it was immunogenic and hadn’t caused serious adverse effects in a few hundred volunteers. Unfortunately in my practice it seemed to cause a lot of sore arms, and one patient had an unexplained neuropsychiatric illness characterised by confusion, amnesia and peripheral weakness a few days after her shot. She took many weeks to recover, during which I decided I was probably immune and didn’t need the vaccine. Now at last the real evidence on the safety of H1N1 vaccine is out: what appears to be a meticulously conducted prospective study of a mere 89.7 million Chinese vaccine recipients. Most of the 8067 serious reactions were straightforwardly allergic: neurological reactions including Guillain-Barré syndrome were no higher than the background rate. So really I have no excuse not to roll up my shirt sleeve this autumn.

648   “Do you think it’s strep, doctor?” is a question always posed in an American accent. In my experience, these patients are better at showing their throats too: none of that British gagging and tongue wagging through a barely open mouth. They have come for their penicillin and they go out with it, only half satisfied because I haven’t taken their vital signs and done a throat swab. Judging from this review of streptococcal pharyngitis, what the well-informed modern American with a sore throat really expects is a near-patient rapid antigen-detection test, and I think the author makes a reasonable case for this rather than the indiscriminate use of antibiotics. But what is really missing from this account is any in-depth discussion of the rare but serious complications: peritonsillar abscess, rheumatic fever, glomerulonephritis and Lemièrre’s syndrome.

Lancet  19 Feb 2011  Vol 377
650   I wish I knew what to do with children and adolescents with mild persistent asthma, and so did the worthy investigators of the TREXA five-centre US RCT of four treatment strategies to prevent exacerbations. This is a tougher call than it may seem: they recruited 843 children but ended up with 288, meaning just 71-74 for each of the four treatment arms. The active interventions were inhaled beclometasone and albuterol. The placebo group had the most exacerbations and the greatest need for rescue treatment over 44 weeks, as expected. Those taking a small – 40mcg – dose of inhaled beclometasone twice daily did best. But the group who just took beclometasone at the first hint of an exacerbation did almost as well. The moral perhaps is: use much smaller doses of inhaled corticosteroid than the 100-200mcg bd. that we still often see used for adolescents; try rescue inhaled steroids in the best controlled; and don’t confuse “compliance” with quality of treatment.

658   Eeh lad, it’s CHAMPION, the things they can do for folk with ‘eart failure these days. But in this study, CHAMPION is not a Yorkshire term of approval but stands (wait for it) for CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients. No prejudging of the study outcome here then. My guess is that CardioMEMS will be ordering a stack of reprints to reward The Lancet for publishing this openly promotional study. Did patients with this implantable device to measure pulmonary artery wedge pressure feel any better, or worse? Will they live longer? We have no idea, but at least they had fewer hospital admissions over a 6-month period. The only other outcome measure was technical device function. It’s time that somebody did some better championing for heart failure patients, based on other, longer, patient-important, outcome measures.

BMJ  19 Feb 2011  Vol 342
421   The hypothesis that enterovirus infection acts as a trigger for the development of type 1 diabetes in susceptible children has been around for over 40 years, but it is remarkably hard to find clear evidence. Perhaps the best hope lies in studies using molecular methods to detect the viruses: there are plenty of them, and they are hard work to sift through, so congratulations to Wing-Chi G Yeung, the medical student from Sydney who did most of the work here. He or she finds that there are indeed strong associations between several enteroviruses and childhood diabetes.423   The North is a pejorative term in Southern England: people who live above a line between the Severn and the Wash are looked down upon as coarse, shabby, and prone to vote Labour. It was not always so: the greatest flowering of Anglo-Saxon culture centred on Northumbria in the eighth century, the great diocese of Lincoln stretched south beyond Oxford, and the houses of York and Lancaster ruled over late medieval Britain. Perhaps it was the coming of the Industrial Revolution that really created the North-South divide, and fixed the dividing line around the latitude of Birmingham, a rural village which became a sprawling city of smoke and iron. From then on, people up North, especially males, died faster – a trend which continues at around 20% with remarkable consistency to this day. It really is grim up North.

424   The dangers of low dose ionising radiation remain difficult to quantify, despite the much-debated work of pioneers like Alice Stewart and Ernest Sternglass fifty years ago. This latest attempt is a case-control study of childhood cancer in relation to exposure to X-rays (and also non-ionising sound waves, as in ultrasound scanning) in utero or in infancy. The sound waves are harmless, and the X-rays are probably a risk, but one which doesn’t reach statistical significance except possibly for lymphoma in this UK study with 2690 cases of childhood cancer and 4858 controls.

426   A Dutch clinical review of islet transplantation in type 1 diabetes recollects the high hopes we had of this therapy ten years ago, and explains why they have faded. Isolating beta cells from cadaveric pancreases is a crude and tedious process: after injection into the portal vein, they take up tenuous residence in the liver but gradually cease to function despite continuing immunosuppressant treatment. The best one can hope for at present is not a cure for diabetes, but merely a reduction in insulin requirement and the risk of hypoglycaemia, in exchange for a lifetime of potentially dangerous anti-rejection drugs. The breakthrough will only come when we can manufacture islets of beta-cells which function indefinitely without immune suppression, using the patient’s own precursor cells.

433   Meanwhile, we have a new drug class for type 2 diabetes, glucagon-like peptide-1 analogues, also known more simply as incretin mimetics. All of us have been urged by our diabetologist colleagues to start patients on exenatide and liraglutide, and we meekly obey, because they are the experts, after all. But experts at what? It was they, after all, who persuaded us to use rosiglitazone on many of these patients a few years ago. So just consider whether you really should be following their expensive advice this time round, giving your patients drugs which need to be regarded as experimental until we know their long-term effects on hard end-points.

Arch Intern Med  14 Feb 2011  Vol 171
196    Miriam Johnson and I compiled the first book on heart failure and palliative care five years ago, aimed mainly at a UK audience. I don’t know if it’s sold any copies in the USA, but a new survey of resource use in the last 6 months of life among Medicare beneficiaries with heart failure shows a huge rise in hospice use by these patients between the beginning of 2000 and the end of 2007. The official Medicare policy remains to distinguish between “palliative” and “curative” treatments, but it is good to see that such distinctions seem to be little heeded in this group, who have also been given more intensive medical treatment as well. I had hoped to say goodbye forever to this gloomy subject, but I think the need to identify patient-important symptomatic outcomes in heart failure remains huge, as does the need to provide better end-of-life care: so I might get out my pen once more.

211   The Canadian health system is very different, but the same trends can be observed there too. Hospital admissions in the last 6 months of HF are decreasing, but costs are increasing. Commissioners take note: there are no cheap ways of helping heart failure patients to live longer, or die better.

Plant of the Week: Helleborus viridis

This isn’t really a garden plant, unless (damn you) you are lucky enough to have a large area of shady woodland in your demesne. There, among your wonderful drifts of snowdrops and winter aconites (I hate you more and more) you will have ensured the brilliant green presence of this striking native hellebore.

Like the rest of its family, it is poisonous in every part, but attractive both in leaf and flower. It is a true woodlander, with inky green cut leaves to absorb any light that penetrates the broadleaf canopy later in the year. In the bare months of winter it gets a little more light and gathers up the energy to produce its tall flaccid stalks of striking pale green flowers in February and March. Unless you have planted some of your own, you will only find it in the deepest darkest parts of deciduous woodland, where it shines like Satan disguised as an angel of light.