Richard Lehman’s journal review – 11 April 2011

Richard LehmanJAMA  6 Apr 2011  Vol 305
1305   Postmenopausal oestrogen protects against breast cancer. Now there’s a headline I never thought I would write; and yet it’s the clear conclusion of this follow-up study of the women in the Women’s Health Initiative Estrogen-Alone Trial. In this unique double-blinded RCT, over 10,000 women aged between 50 and 75 who had a previous hysterectomy were randomised to 0.625mg conjugated oestrogen or placebo. Figure 3 gives the cumulative plot for invasive breast cancer: it could not be clearer. At 12 years, the risk line is still diverging in favour of the oestrogen-treated group, HR 0.77, 95% CI 0.62-0.95. All cause mortality was the same in both groups. And while we are on the subject of counter-intuitive results about cancer risk, I’ve just read a letter in the BMJ Rapid Responses pointing out that in the 20-year follow up study of PSA screening from Sweden in last week’s printed issue, there is a clear mismatch between the conclusion and the statistics given: “After adjustment for age at start of the study, the hazard ratio [for prostate-related death] was 1.58 (1.06 to 2.36; P=0.024). Conclusions: After 20 years of follow-up the rate of death from prostate cancer did not differ significantly between men in the screening group and those in the control group.” But it did differ significantly: PSA screening raises your risk of dying from a prostate-related cause, by perhaps 58%. And I missed this, because like most of you, I find my eyes glazing over whenever PSA and screening are mentioned. It so shouldn’t be done.

1315   What’s the second leading cause of unnatural unintentional death in the USA, after motor vehicle crashes? Gun crime? No – it’s unintentional opioid overdosage. This veteran’s administration study examines the relationship between levels of opioid prescribing and death from opioid overdosage: it is clear and large. Oddly it is lowest for those with substance addiction and highest for those with cancer, perhaps because the unpredictability and intensity of cancer pain leads people to take high doses without habituation. The editorial is thoughtful but does not mention another factor which must play a part in the US epidemic of opioid-related death: very easy access to oxycodone (the main culprit drug) on the internet. If I took up all the invitations in my Spam folder, I would be dead in short order. Though with lots of impressive watches, several degrees, two Russian brides, and formidable private dimensions.

1350   A couple of the best pieces this week are on the subject of type 2 diabetes (see Lancet). The message is finally getting through: one size does not fit all, and glycaemia is not the most important outcome by a very long chalk. In fact it matters very little in most frail elderly people with short life expectancy, as this excellent commentary piece from San Francisco points out.

NEJM  7 Apr 2011  Vol 364
1315   The armed forces of Israel keep a close eye on the health of their personnel by means of a research programme called MELANY. In this study, they look at the body mass index at the age of 17, when the men were recruited, and analyse its relationship with the later development of diabetes and coronary heart disease between the ages of 25 and 45. This is assuredly not a time of life when you want either of these conditions, and we must also remember that these men were mostly operating at high levels of exercise and fitness. Nonetheless there were enough cases to establish a clear relationship between BMI in youth and later CHD, starting from well below the obesity range. There is also a weaker relationship between BMI in youth and the early onset of type 2 diabetes, but this is entirely accounted for by a relationship with BMI at the time of diagnosis.

1360    From time to time, doctors and politicians look across the Atlantic ocean to see what lessons might be learnt from comparing the UK health reforms with the US health reforms and vice versa. Here Martin Roland and Rebecca Rosen provide a superb guide for Americans who are perplexed as the “English NHS Embarks on Controversial and Risky Market-Style Reforms in Health Care.” Now I have just finished reading Jack Wennberg’s magnificent book about American medicine (Tracking Medicine, OUP 2010) in which he lays out the following principles for a reformed US system:

1. Promoting organized systems of health care delivery
2. Establishing informed patient choice as the ethical and legal standard for decisions surrounding elective surgeries, drugs, tests, and procedures, and care at the end of life.
3. Improving the science of health care delivery
4. Constraining undisciplined growth in health care capacity and spending.

Roland & Rosen provide a Table 2 showing the differences between the US modes of provision and the proposed English reforms; my slightly less nuanced comparison of Lansley with Wennberg would be:

1. Destroying organized systems of health care delivery
2. Establishing “nothing about me without me” as a political slogan without any infrastructure of decision support for patients: their GP will decide according to the budget allocated.
3. Ignoring the science of health care delivery
4. Constraining necessary growth in health care capacity because there is no mechanism for matching supply with informed patient demand.

Lancet  9 Apr 2011  Vol 377
1220   You’ll look in vain in this week’s Lancet for research papers of general interest, but here is an editorial which every doctor needs to read: Intensified glucose control in type 2 diabetes—whose agenda? It’s written by three senior academics in the field who almost alone have been prepared to look carefully at all the evidence and in particular at the absolute benefit (or lack of it) from tight glycaemic control for different kinds of diabetic patient. As they point out in one of many brief, telling sentences, “The most entrenched conflict of interest in medicine is a disinclination to reverse a previous opinion.” Which sits perfectly with their final statement, ” We declare that we have no conflicts of interest.”

1224    The Lancet contains a weekly column called “Offline” in which Richard Horton informs us what he is doing instead of editing The Lancet. This one starts “I went to Trondheim last week to see Julian Tudor Hart”. In fact JHT was not in Trondheim but back at home in South Wales: but hey, the fjords are better in Norway. I commend your attention to this week’s “Offline” simply because it draws good comparisons with political decision-making about health in Norway and Scotland compared with modern-day England. How wonderful it would be if we could use Lansley and Cameron’s “listening period” to bring into reality the Tudor Hart concept of doctors and patients as “co-producers of health” – an idea which has lost its Marxist connotations and appears equally strongly in the Wennberg book I mentioned previously. But that means trusting patients to make informed decisions about care in their locality, and giving them the means to provide it. “Goodness me, Humphrey, we can’t have that – it almost smacks of democracy.” “Yes, Minister.”

1264   Viral pneumonia is a diagnosis we rarely dare to make in primary care: if somebody has a fever and chest signs, they get amoxicillin. If they don’t respond, they get another antibiotic. If they get too sick, they go to hospital. That’s what happens the world over, from Turku, Finland, to Christchurch, New Zealand, the two antipodes represented in this joint seminar. It’s full of interesting detail, especially about viral co-infection, but it is unlikely to change practice since procalcitonin has not lived up to early promise and we still have no reliable means to distinguish viral from bacterial infection.

1276   A worthy account of osteoporosis: now and in the future comes from Dresden, and describes whole new classes of drug to treat this “common disease.” But is osteoporosis best characterised as a disease, and don’t we have perfectly good drugs to treat it with already? As each new pathway is elucidated, points like this begin to RANKL with an old Dickkopf-1 antibody like me. Say no to disease-mongering, however clever the science and tempting the market.

BMJ  9 April 2011  Vol 342
778    DMG Halpin is a respiratory specialist appalled at how bad we are at diagnosing COPD. There are “missing millions” of British citizens who have not been honoured with this depressing label and who “just expect to be told to stop smoking rather than receive a diagnosis and treatment if they do consult a doctor”. It’s quite shocking: you have to go to Kyrgystan to find anything so shoddy. Some of us even prescribe smoking cessation aids without doing spirometry and prescribing an armload of useless inhalers.

808   Emergency primary care is an emerging specialty of urgent care into which I am emerging with urgency. It’s not really like old-fashioned general practice because long-term care is missing: but you do see an awful lot of sick babies and it’s a relief when the season of acute bronchiolitis comes to an end. That’s because neither oral steroids nor inhaled beta-adrenergic agents make any difference: but this meta-analysis does identify one trial where adrenaline by nebuliser plus oral corticosteroid made a significant  difference. I guess we need to lay in some of these for next November.

810   The other thing we could lay in for November is a great big tub of simvastatin. Then, as the pneumonia season arrives, we could put every susceptible patient on a small dose and halve their short term mortality after a pneumonia episode. Mind you, they need to be taking the stuff before they get the infection, according to this observational study. Previous miraculous effects of statins have not been confirmed by randomised controlled trials, so we need one right away.

812   TIA for transient ischaemic attack has entered popular parlance just in time for the term to be largely binned by neurologists. Most “TIAs” lasting for more than a few minutes are associated with detectable brain infarction and are followed by larger strokes within 7 days in 5.2% of cases. This is a good brisk Glaswegian Clinical Review of how to diagnose TIA and stroke – remember ROSIER, FAST and ABCD – and how to treat it. Despite much greater public awareness of the urgency of stroke management, and the growth of specialist services, use of immediate thrombolysis remains conservative on both sided of the Atlantic, perhaps in acknowledgement of its marginal benefit.

Plant of the Week: Bergenia “Beethoven”

The bergenias are creeping plants of the saxifrage family, raised by German nurserymen to grow fleshy leaves of heroic proportions, and flower spikes varying from pure white (Silberlicht) to alarming shades of mauve and magenta. We chose this one for its name, of course. If you wish to indulge in garden wit, you can place it next to “Eroica,” or with all the major nineteenth century composers whose names began with B – Brahms, Bizet, and Borodin, with Bartok straying into the twentieth.

But in the garden as in music there is nothing to compare with Beethoven. When we first bought him, he produced dazzling white flowers in late winter. Then we transplanted him and he entered his second period, breaking from deep pink buds into flowers of white tinged with pink in March. Now he has entered his third period, pinker and later than ever. I am afraid this does not resemble the original Ludwig van Beethoven, who became ever more wonderful with time – let JWN Sullivan’s Beethoven: His Spiritual Development (1927) ever be your guide. As for the bergenia, I am beginning to think we had better get a new one.