Richard Lehman’s journal review – 31 May 2011

Richard LehmanJAMA  25 May 2011  Vol 305
2071   Idiopathic sudden sensorineural hearing loss: now that’s the kind of medical label I can do business with – the kind that tells you what is happening and that we don’t know why. The “sudden” bit may be literally true or refer to a period of up to three days. When I was planning the Easily Missed series, I wanted to include this topic, as some GPs seem unaware of its existence; but the idea was rejected because we don’t really know if early recognition and treatment makes a difference. The standard intervention is a course of high-dose oral steroids, but in the USA a fashion has spread for giving intratympanic steroids instead. I wonder how this correlates with payment systems for ENT surgeons in particular health settings. Anyway, this trial proves the two are equally effective – or ineffective.

2088   If you want an easy win, get some frozen blood samples from a cohort study and measure a new prognostic biomarker. In a cohort of heart failure patients of mean age 73 followed up for 13 years, there are bound to be a satisfying number of deaths, so bingo, there’s your paper. This has absolutely no bearing on the way any biochemical test is used in real life. But at least these investigators compared the best currently available prognostic marker, B-type natriuretic peptide (here in N-terminal form) with the latest contender, copeptin, a breakdown product of arginine-vasopressin. Moreover, they looked at its additional prognostic value by ROC area comparisons, which, for reasons too lengthy to explain here, is the right thing to do. But why do it at all? In real life, if you were interested in biochemical guidance for patient treatment or prognosis, you would do sequential tests. And most probably, due to cost and random variation, you’d find it wasn’t worth doing: as we are likely to find with BNP and copeptin. 

NEJM  26 May 2011  Vol 364
1195    For reasons that it is not for us to question, most new rescue drugs for advanced cancer end up costing about $5-20K for every month of life gained. Abiraterone for prostate cancer seems to fall into this category when given to men who have become non-responsive to goserilin and have received chemotherapy – there is 4 month mean survival difference. For all we know, this drug, which blocks the biosynthesis of testosterone at a cellular level, may be best used at an earlier stage of the disease process, but how are we ever to use it at all when it costs so much? Apparently some centres are finding that a similar blocking effect can be obtained using ketoconazole at £40 a month, but there are no head-on comparisons: a NICE dilemma.

2006    Most medical labels are stupid, but asthma wins a special prize. If you ever find yourself wheezing, it is essential to avoid doctors unless this seriously interferes with your life. You are bound to have this label branded on your forehead and be put on a register and given drugs which do not alter the course of the condition and be plagued with reminders to attend for futile consultations for the rest of your life. That’s not to say it can’t be a serious and life-threatening condition – just that we use the label so freely that nobody can tell what it means. This basic science study adds to our confusion. 48 “subjects with asthma” were challenged with an inflammatory allergen (house dust mite) or a simple bronchoconstrictor (methacholine) or with one of two placebos. We learn from the two active groups that similar changes in subepithelial collagen-band thickness occur at 4 days whether or not there is an inflammatory response – in other words, that this presumed marker for airways remodelling occurs purely in response to bronchoconstriction. It’s nice to see some old-fashioned experimental work in the NEJM, but I’m not sure that this bronchial biopsy study is ever going to lead to new  paths in the long-term management of asthma. But there’s an outside chance it might, and at least it’s real science.

2016   Good data collection counts as science too, and this survey of bacterial meningitis in the US, 1998-2007 is meticulous and fascinating – though we in the UK need local data too. The big surprise to me was to learn that the meningococcal infection now only accounts for 14% of infections, while S pneumoniae has become by far the most common pathogen at 58%. Group B streptococci, H influenzae and Listeria monocytogenes account for the rest. Another startling (to me) fact is that the median age of patients has risen to over 40, while incidence has fallen by 31% during this period. The case-fatality rate in the USA however remains stubbornly near 15%.

2037   What cannot ever count as science, however, is borderline personality disorder, the indefinable subject of this review. You can pretend to do science around “it” – tracing its heritability, measuring the amygdala, and so forth and so on; but in the end you are but a pale imitation of Miss Marple sitting over a cup of tea, saying there was once Doreen the waitress in St Mary Mead, who came from a bad family, and that it was perfectly clear from when Doreen first wore lipstick that no good would ever come of her. 

Lancet  28 May 2011  Vol 377
1837  The two therapeutic trials in this week’s Lancet are a stark reminder of the realities of medicine in the “developing” versus the “developed” world. This first one discovers whether you can safely stop ceftriaxone after five days as opposed to ten days in confirmed cases of purulent meningitis in children due to S pneumoniae, N meningitiditis or Haemophilus influenzae type B. Yes you can, saving maybe £25 on ceftriaxone and a bit more on bed space.

1846   Now we look at 637 people of mean age 65, spread across 177 sites in 12 developed countries. They have non-small-cell lung cancer and they have all undergone standard chemotherapy.  Whatever we do next, they are going to die, most at an age below normal life expectancy in the West. What price an extra few weeks of life? They all receive erlotinib, which costs about £1,700 per month. Half of them additionally receive bevacizumab, the Genentech drug we met with last week in the context of macular degeneration. This costs only about £500 per month. Unfortunately it makes no difference at all: mean survival in both groups was 9 months.

1855   And here is another of those global surveys that Richard Horton likes almost as much as multicentre pharma-funded studies of expensive drugs. This one is a global reference for fetal-weight and birthweight percentiles: not something I am going to need very often; but you might, and here you can find it. Pure virtue and free of any funding, according to the declaration.

BMJ  28 May 2011  Vol 342
1192    There are some places where physicians should never venture, for fear of upsetting long tradition and useful belief systems. For example, if you really knew what podiatrists say or do, would you ever send a patient to one? I merely pose the question: I have no idea of the answer. I declare to the patient that I shall be referring them to the podiatrist and that they can now put their socks and shoes back on. This is sometimes accompanied by surreptitious activation of the electric fan. Now part of the mysterious armamentarium of the podiatrist is the lateral wedge insole, which helps to redistribute weight bearing not just in the foot but right the way up to the knee, allegedly. So are lateral wedge insoles, worn for a year, capable of slowing the progression of medial knee osteoarthritis? Not in Australia, according to this nice straightforward trial. But then they do walk upside down.

1193   A positive trial for the prevention of pre-eclampsia is a rare and notable event. The intervention was cheap and simple and the effect size was impressive: in these high-risk women in a Mexican tertiary centre, 30% developed PET in the placebo arm, as opposed to 13% who were given L-arginine and anti-oxidant vitamins. The problem here is not statistical validity but generalisability – not everyone looks after high-risk Mexicans, as the authors are the first to point out. More trials in other centres please – with this effect size, they don’t have to be large, and they don’t really have to last for more than nine months.

1194   Of all the tools we use in what we are pleased to call medical science, the food questionnaire must rank as about the least accurate (though there are many close contenders). Still, if anyone is going to fill them in properly, it must be the Swedes, with their limited local diet and long winter evenings. From these confessionals we can plot a relationship between dietary calcium intake and risk of fracture and osteoporosis in older Swedish women over a 19-year period. We can conclude that such women should take at least 700mg of calcium daily and stop wanting to look after Wallander because he is such an emotional wreck.

1199   More Ozzie orthopaedics of the highest order is to be found in this clinical review of the management of tennis elbow, co-written by someone who gives his address as “Australian Cricket Team, Melbourne, Australia”. In case you can’t find him in the batting order, he is their physiotherapist. This common condition has reverted to its common name because all the fancier terms like “enthesiopathy” and “epicondylitis” are misleading – but then so is the reference to tennis. It’s just a result of overloading or underloading at the common extensor origin and the best treatment is time and possibly eccentric exercise as illustrated on paper and video with this review. Avoid corticosteroid injections as they tend to prolong the problem.

Arch Intern Med  23 May 2011  Vol 171
887   When QOF has been abolished and primary care teams can return to having time to talk to each other and develop their own priorities, high on the agenda should be the provision of brief behavioural treatment for chronic insomnia in older adults. In this American study, it was administered by nurses, but there is no particular reason why others should not do it. The first session takes about 45 minutes, the second 30 minutes, and then there are two follow-up phone calls. It was highly effective compared to a written advice sheet, and improvements were maintained at 6 months.

914   A couple of weeks ago we learnt that inhaled anticholinergic treatment in COPD may well increase mortality, and here we learn that it is associated with acute urinary retention in men. The ones at highest risk, not surprisingly, are those with known prostatic hypertrophy. It might be worth checking your practice registers for co-prescription of anticholinergic inhalers and drugs like tamsulosin which are markers for BPH.

929   Current orthodoxy in palliative care asserts that we should discuss the possibility of dying with patients early in their disease trajectory and involve palliative care teams at an early stage. I have always been a sceptic on this, and here is a study that shows optimism is good for you and your survival is likely to be longer if you think it will be. It charts survival over 19 years in a cohort of people undergoing coronary angiography in a single tertiary hospital. “These observations add to a compelling body of evidence that endorsing optimistic expectations for one’s future heart health is associated with clinically important benefits to cardiovascular outcomes.” Meanwhile, in the June BJGP, there is a good study from Patrick White and others contesting the universal desirability of involving palliative care teams in advanced COPD.

Plants of the Week: Tall Bearded Irises

Here they are again, the huge blowsy flowers we look forward to every year, smelling of everything nice from fruit salad to chocolate. Battered by wind and rain and eaten away by slugs, they still manage to look both stately and outrageous. There is absolutely no point in looking for named varieties unless you want to get one named after a loved one. Otherwise just go to a nursery that sells lots of varieties and choose the ones that you can’t resist.

Current favourites in our garden are a great big creamy one which smells of lemon syllabub, a tangerine one with frills which smells of wine gums, and a dark one with hints of cocoa. It is hard to figure out how such flowers can persuade themselves to appear in cold grey England. Enjoy them while they last and bring them into the house if there are any to spare.

After flowering, they are a bit of a nuisance – you must split them, halve the leaves, and replant them where their corms will be warmed by the sun, labelling each as you go. You will wonder why you bothered, until it is iris time again.