Richard Lehman’s journal review – 9 May 2011

Richard LehmanJAMA  4 May 2011  Vol 305
1769    When I first started writing comments on the medical journals in 1998, coronary artery bypass surgery had become the commonest major operation in the developed world. The alternative was balloon angioplasty, though increasingly this was being augmented with the insertion of bare metal stents. And then, as most of you know, came the Stent Wars, as interminable as the border wars between the Romans and the Parthians, about as interesting, with similar exotic names for the competitors (Sirolimus, Paclitaxel etc). It was at this point that the words “stent” and “elute” re-entered the English language in full glory. And what joy these words bring to us every week, a sure signal that we can quickly turn to the next paper. But this paper is actually very interesting, because it maps the changing fortunes of each of these coronary revascularization techniques in US clinical practice between 2001-2008. However, there is no need to read the text: everything you need to know is on figure 1.

1777   And there is another figure on the JAMA website which will really make you rub your eyes. We all know that high salt intake increases blood pressure and so contributes to the Western epidemic of cardiovascular disease, right? Totally wrong, actually. As measured by daily sodium excretion, salt makes hardly any difference to systolic BP and none to diastolic. And the less salt you take, the higher your risk of cardiovascular death. No, that’s not a typo: it is a fact established in a study of 3681 subjects across Europe intensively followed up for 8 years. Look at the chart and wonder: and celebrate by buying Mark Kurlanski’s fascinating book Salt: a World History (2002) and by finding a big wild sea-bass to bake au gros sel.

1790    Not everything in medicine is counter-intuitive, and I would be prepared to bet quite a large sum that exercise is good for people with type 2 diabetes. My hunch is that it prevents blindness, limb loss, coronary artery disease, and cardiovascular death; and also makes people feel better. But all this systematic review shows is that it lowers glycated haemoglobin, which is another thing entirely, as you should all realise by now.

NEJM  5 May 2011  Vol 364
1695    Large double-blind randomized trials are extraordinarily labour- and cost-intensive, and when they are done, people like me are apt to tell you they don’t mean much for the patients you see every day. Is there an alternative to be found here – a  good pragmatic British compromise? (For those who don’t already know, this is code language for quick, cheap, and dirty.) Well, in some situations, such as the treatment of asthma symptoms, perhaps there is. And for those of us who work in British general practice, it certainly warms the cockles to see the New England Journal leading with studies conducted on our premises and with patients such as we see every day. Moreover, the two studies reported in this single paper attract two very good commentary pieces. Best of all they address an important and practical issue: how should we be combining the leukotriene antagonists (montelukast and zafirlukast) with other treatments in adults with asthma? Essentially, the two studies – too much detail to describe here – prove equivalence between these oral drugs and inhaled long-acting bronchodilators and corticosteroids in the short term and almost prove it at two years. Bear in mind that (a) these drugs will shortly become generic and (b) no treatment we know of alters the natural history of asthma.

1708    As I near the age when I am more likely than not to have carcinoma-in-situ of the prostate, I read each paper about the treatment of localised prostate cancer with increasing interest, not to mention increased tensing of the pelvic floor muscles. Fortunately, some of the right interventional studies are being done and may be completed before my turn arrives. I would like to avoid radical prostatectomy if possible (preferring the slower route to incontinence and impotence), but this 15 year report of a randomised Swedish trial shows survival benefit for symptomatic men under 65 whose localised cancer was discovered by rectal examination. For everyone else with localised prostate cancer, the choice is still unclear, as you will learn if you have access to the wonderfully lucid editorial.

1718    If you’ve taken my advice and pored over the chart in this week’s JAMA, you’ll have seen how the slight fall in coronary artery bypass grafting in the last decade in the USA has been pretty well matched by a rise in the use of drug-eluting stents. Few cardiologists seem to have had the COURAGE to discourage patients from revascularisation procedures altogether. I suspect the same applies in Korea, where this head-on randomised comparison study was carried out. Those who had CABG and those who has sirolimus-eluting stents for left main coronary artery disease fared similarly at two years: this trial really doesn’t tell us much we didn’t already know. 

Lancet  7 May 2011  Vol 377
1573    Seeing the word appendicectomy in the title of this paper is a rare reminder of the fact that The Lancet is still a British journal – though the regrettable Americanism “appendectomy” can now be heard on the lips of many who should know better, including even the redoubtable Dr Alan Statham of Green Wing. Now in France, appendicite is generally treated with appendicectomie as you would expect, though one on-line dictionary gives this as apprendicectomie, which seems a bit drastic. Certain brave Frenchmen decided to run a randomised trial of co-amoxiclav versus surgery for CT-confirmed acute appendicitis. Those treated conservatively with this antibiotic had a higher rate of peritonitis, and within a year a third of the patients needed appendicectomy. So, as the abstract puts it, “Amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis.” Now I know that “non-inferior” is a sacred medical term, but to express the result in this way is not non-ridiculous.

1600   It’s nasty, not very common, of unknown origin and has no really effective treatment – so it’s the perfect subject for a learned review in a leading medical journal. Primary biliary cirrhosis is ten times commoner in women, is associated with antimitochondrial antibodies, is treated with ursodeoxycholic acid but often ends up requiring liver transplantation. If you need to know more, get your local medical librarian to send you a copy of this nicely written seminar.

BMJ  7 May 2011  Vol 342
1010   As a regular taker of an angiotensin receptor blocker and a regular reader of the medical journals, I was apparently supposed to worry about an increased risk of myocardial infarction. I’m sorry if I fell short on this count, because it makes it all the more boring to report that no such association exists. This study is a meta-analysis of 147,200 patients enrolled in RCTs of ARBs who completely failed to have more heart attacks.

1011   My impression from the literature is that we probably over-diagnose and over-treat hypothyroidism. There is some evidence that suppressing TSH can increase mortality: here is some evidence that it can increase fractures in the elderly. Let moderation be your watchword and keep doses of T4 below 75mcg daily in little old ladies if you can.

1014   I don’t think I’ve ever been asked about laser refractive surgery except by one of my children, who was duly confirmed in the view that I’m not a proper doctor as I’m so clueless about everything. Ophthalmology is certainly not my strong suit, so I shall never make a fortune or rule Syria. For a start, I can’t even work out basic eye-language, though I did Greek to O-level. Keratomileusis for myopia, hyperopia and astigmatism(os) indeed. But here is a nicely written and illustrated guide should you want it.

Ann Intern Med  3 May 2011  Vol 154
573    Here’s a nice contrast with the pragmatic, publicly-funded asthma trials in this week’s NEJM: an industry-sponsored trial of a very expensive agent, omalizumab, in a carefully selected group of patients with severe allergic asthma. Fewer than five such patients were recruited from each of 193 investigational sites. The trial lasted less than a year and success was judged by the number of exacerbations needing oral steroids and the use of rescue albuterol. On these criteria, omalizumab just about did the bizz, but I suspect its use in the UK will be restricted to very labile patients in specialist centres.

583   A couple of weeks ago, a West Country chest physician lambasted British GPs in the BMJ for being so bad at diagnosing chronic obstructive airways disease. I could understand this if we had an effective means of changing the natural history of the disease, aside from encouraging people to stop smoking. But in fact the interventions we use for symptomatic COPD may actually increase mortality. This has been suggested for inhaled long acting beta-adrenergic (LABA) drugs, and now along comes this study from Ontario suggesting that inhaled anticholinergics are actually more dangerous than LABAs. This was a big cohort of elderly people with COPD and the mortality difference was only just significant and not very great. Nonetheless, we need to be very sure the interventions we use in elderly COPD patients are actually improving the quality of their lives, since there is no evidence that they increase their duration.

602    When I read papers like the last one I sometimes think that there is hardly any common ground among what we call “chronic diseases,” except for our uselessness at managing them. Type 2 diabetes is the example I’ve worked with most in the last couple of years. This is a risk collection which becomes less important the older you are when you get it. It is terribly important if you get it in your teens, twenties, or thirties, but we have no evidence at all about what will affect outcomes in young patients: we hope that tight glycaemic control will help and we try and achieve it any way we can. By contrast, someone getting T2DM in their 60s can be kept on a fairly loose leash – at least we have good evidence for that. And each particular agent has its own risks, as we know from the rosiglitazone saga. Maybe each combination of agents has its own risks – we have less evidence about that. Anyway, here is the latest summary of what we do know about the relative benefits and adverse effects of the individual agents and the combinations, as far as we know them, brought to us by a team from Johns Hopkins. Metformin is good, everything else is shrouded in doubt – the usual message.

627   Now in the UK, the management of diabetes, like that of several other “chronic diseases,” is governed by a one-size-fits-all model which we must obey on pain of losing part of our income. It is much easier to do useless things for people who are relatively well than hard things for people who are treatment-resistant or non-adherent. And every year the QOF must get tighter, or GPs will slacken and earn too much, which they do already. So every year, with guidance from NICE, the wise and the good and the wily sit down together and work out how far GPs should be pushed next year. And the GPs duly do more and more things for people who need them less and less. There may be a different way of doing things: pray God it comes in time to rescue what sanity and professionalism remains in our ranks. This paper suggests part of the solution – its title is Individualized Guidelines: The Potential for Increasing Quality and Reducing Costs. The other part of the solution lies in patients themselves deciding what risks they are prepared to bear and what outcomes they personally would like to achieve: be warned that you will hear a lot more about that from me. We could even look forward to an honest and cooperative relationship between doctors and patients, a truly outcomes-centred research agenda, reduced costs through reduced demand and better targeting: what’s stopping us? Quite a lot – but it’s time we got rid of it.

Plant of the Week: Magnolia sinensis

This lovely small tree is hung with the most beautiful and sexily fragrant flowers for two or three weeks in late spring, but is oddly rare in our gardens. The petals are pure white and centred around a deep crimson boss. Had it been imported into England a couple of centuries sooner, Andrew Marvell would have given it an entire stanza at the ecstatic heart of his poem, The Garden.

Although our gardens are small, we have also found room for the close relative of sinensis which is named for the greatest of plant hunters, Ernest Wilson. You can only tell M wilsonii from sinensis by counting petals. Sit beneath either, like Marvell, and look up at the white lamps hung on sparsely leaved branches, the sky blue beyond. Your soul will break free to join the scented air.