JAMA 13 July 2011 Vol 306
Unusually, I couldn’t find anything to report on from JAMA this week. Last week, its new editor, Howard Bauchner, promised us a new vision for the journal. I liked the old journal very much but it was becoming like an old jumper *– full of comfortable associations but saggy with holes and patches. I hope HB realises that the days of “high prestige” printed journals are coming to an end, and that by the end of his editorship we need to have an open-access, interactive JAMA.
*For American readers I should explain that a jumper is a kind of British knitwear which approximately covers the thorax. It is usually exchanged at Christmas, and in extreme cases is hand-knitted.
NEJM 14 July 2011 Vol 365
107 When you read the word prostate in the title of a paper, expect confusion. And be accordingly grateful if you come away slightly more enlightened than before you read it, as in the case of this study of Radiotherapy and Short-Term Androgen Deprivation for Localized Prostate Cancer. As a result of a carefully designed trial which began in 1994, we can be reasonably certain that for localized prostate cancer of intermediate Gleason score, it is worth giving a few months of androgen suppressing treatment around the time of external beam radiotherapy. In fact this can only be deduced from a post-hoc subgroup analysis, and the effect size is not large. But there is a balance to be discussed with patients here, with a single-figure percentage increase in long-term survival to be set against a short-term increase in impotence and myocardial infarction.
119 Here is a study which should make all doctors squirm a bit. We are all committed to honesty, I hope, both to ourselves and our patients. And yet repeated studies of the placebo effect show that our honesty can deprive patients of large subjective benefits. For example, we all know of patients with real or presumed asthma who consume enormous quantities of beta-adrenergic inhalers without any objective evidence of severe bronchoconstriction. A few of them probably die as a result. We suspect that they would get equal symptomatic benefit using a harmless placebo inhaler, and this pilot study from Harvard goes some way to demonstrating that. I say “some way” because the study seems to have timed the interventions to suit the investigators, not the patients. They received inhaled albuterol, inhaled placebo, sham acupuncture or simple waiting in cross-over fashion for a total of 12 visits. Inhaled albuterol was the only intervention that improved FEV1 but sham acupuncture and placebo inhaler were as good at relieving symptoms. For thousands of years, doctors were safer using placebos than active treatments; and that probably applies in certain areas today. But to use placebos deliberately is to become a charlatan and to undermine the scientific basis of medical progress. Discuss.
P.S. One of the authors of this study declares direct payments from 20 pharma companies and grants from 9: it would be nice to think he will be doing similar studies on all their products.
Lancet 16 July 2011 Vol 378
This week’s Lancet is devoted to HIV/AIDS, and as some readers will know I have traditionally refrained from commenting on this topic because its global importance is in no way matched by my personal experience of fewer than 10 patients, managed entirely by others with proper expertise. Rilpivirine is the latest anti-retroviral drug to be added to their armoury, and I will leave them to use it according to the evidence provided by two randomized controlled trials.
However, it has been one of the most telling experiences of my professional life to have witnessed the whole HIV/AIDS story unfold, from the mysterious, uniformly fatal “gay plague” of the early 1980s to its present status of a controllable chronic disease affecting large parts of the resource poor world. It has shown us what can be done when the will is there – even George W Bush and some pharma companies come out with some honour in this story – and also what cannot so far be done. For example, I do not give much for the chances of those who want to change the behaviour of men who like to have concurrent sexual partners. And the usual answer to a viral pandemic – an effective vaccine – has been desperately slow in coming, though hope is returning. For this and much else, it is worth reading the review of HIV prevention on p.269.
BMJ 16 July 2011 Vol 343
Ever since the first trials showed that statins reduce cardiovascular risk by about 20%, there have been two schools of thought, the “put ‘em in the water supply” school and the “use our risk score” school. Remember that statins are the only lipid-lowering drugs that have been shown to reduce CV risk, and that they do so without a threshold effect, measured by total or LDL cholesterol or anything else. Whatever your cardiovascular risk, a statin will lower it. Age is a key factor of course: so most guidelines which are based on absolute risk advise more and more statin prescribing as people get older. Not so the subtle Norwegians: they base their advice on the value of the years gained, and this is how the BMJ has printed their suggestions:
- 0-49 years: if 10 year risk of cardiovascular death is ≥ 1%
- 0-59 years: if 10 year risk of cardiovascular death is ≥ 5%
- 0-69 years: if 10 year risk of cardiovascular death is ≥ 10%
Spot the misprints.
If you are a full-time British GP, you are likely to see a child or young adult present with type1diabetes once every decade. I was such a GP for 31 years and saw two, both within the space of two weeks. Such is the play of chance, and it so happened that neither presented in full diabetic ketoacidosis. Does that make me a good GP, or just a lucky one? Certainly we don’t want kids presenting in DKA, so this systematic review looking at the reasons they might is useful: but lack of primary care awareness is only one of many potential factors.
What are the circumstances that favour the introduction of a useless intervention? I would say they are: perceived unmet need; a plausible mode of action; strong willingness for both patients and doctors to try out a new treatment; and financial gain for those supplying the treatment. Actually it doesn’t even need to be a treatment: it could equally well be a diagnostic test e.g. for cancer. We’ve seen it for one weight-reducing drug after another; we’ve seen it for one medical device after another: here we see it for vertebroplasty for recent vertebral fracture. Individual patient data from two randomised trials were pooled and showed no subgroup in which the procedure gave better results than placebo.
Arch Intern Med 11 July 2011 Vol 171
1150 Throughout my GP career I held on to two beliefs: if patients wanted to be seen the same day, it was our business to see them: and that general practice was the art of doing medicine in ten-minute consultations, so it was unprofessional to run late. Putting up barriers and messing about with appointment systems implied that we were somehow not there to serve patients, despite the increasing sums that they (as taxpayers) were providing for our comfort. This excellent systematic review of advanced access scheduling outcomes gives a thoughtful overview of the evidence from the UK as well as the USA on the effects of initiatives to achieve same day access. Unfortunately the studies are of too poor quality and too limited generalizability to reach any firm conclusions. Just do what is right by patients.
1183 The effect of sodium and potassium intake on mortality is a matter of deep communal belief which it is unwise to challenge. A recent European study which showed an inverse relation between measured sodium excretion (as an objective measure of sodium intake) and cardiovascular mortality was the subject of an immediate attempted rebuttal in The Lancet on the basis of insufficient sampling. Whereas this prospective cohort study of 12 000 US adults, based on the remarkably accurate methodology of recollected food intake, will bring comfort to the traditionalists. Sodium – he bad. Potassium – he good. Just wait for my Good Death Cookbook.
Plant of the Week: Lagerstroemia indica
By sheer fluke, the place we found to live in the USA over the summer is directly opposite the Marsh Botanical Gardens at Yale. Now Yale is a rich university, occupying the centre of New Haven and gradually eating up the town, particularly the desirable parts of the northern end. Here the original gardens were laid out by Beatrix Farrand, the most famous American garden designer of her time, a Gertrude Jekyll figure who also designed the lovely grounds of Dumbarton Oaks in Washington DC. In the 1920s, Farrand wanted the gardens to be part of a scheme to make the whole Yale campus into a continuous collection of interesting and decorative plants.
Alas, when the US joined the war in 1941, the garden staff of the Yale Botanical Gardens were laid off, and they have never been reinstated. A large concrete building was plonked in the middle of the resulting wilderness in the late 1950s.
I was writing this column three weeks ago when I found the need to look up the fruit called Apriplum, and to my amazement I was directed to a column called “Plant of the Week” by Eric Larson of Yale Botanical Gardens. It turned out that we two people were writing a column with the same name, about 50 metres from each other.
Eric by himself is charged with the task of reviving the whole outdoor garden which in former days had a summer staff of 8. I wish I had time to help him. He has very kindly let me give you a sample of his delightful work – chosen at random, but to match the season. I have edited it slightly to remove references to social events and some of his musical activities:
PLANT OF THE WEEK
July 17, 2007
Lagerstroemia indicaA plant that I saw in Kentucky reminded me of the plantings that I have done here at the gardens to hide a chain link fence. I planted the first stage of the shrub border in the summer of 2004, and it has started to perform its original function quite well, with the secondary function of providing ornament filing along behind.
The backbone of any shrub border, the skeleton if you will, is the evergreen planting. In deepest winter, it’s nice to have something green to remind us that all is not lost. Amongst the evergreens, I planted combinations that I thought might add to the mélange, while other combinations were completely a surprise to me. I always try to grow a few plants in the garden that I have never grown before, as an exercise in futility, utility or just plain fun.
A plant that I had grown before but in somewhat warmer climes is our Plant of the Week, Crepe-Myrtle. This large shrub/small tree is an excellent three-season plant, with something to recommend it to your attention during summer, fall and winter. Right now, it’s flowering here at the Gardens adding a top note to the madrigal in the shrub border.
Crepe-Myrtle flowers range from white to pink through the purple hues to red. They begin flowering in July here in New Haven, and will continue until frost, if you prune the spent flowers off. The blooms appear on terminal wood, or at the end of the branches of the current year’s growth. There is a range of flower-times depending on the variety, with “Hopi,” “Sioux,” “Yuma” and “Pecos” coming in early, followed by legions of other varieties, many named after tribes or individuals of the First People.
Back when I lived in Kentucky, I took a stab at a cut flower business, (New Giverney Gardens: Not Just In It For the Monet), selling flowers from buckets in a downtown Frankfort courtyard on Fridays using a bicycle-wheeled garden cart. Although I lost money, I learned a thing or two. One thing I found is that by playing guitar, I lured business in with a gusto that would make Barnum blush. But when I started to sing…well, let’s just say that business did not hum like a Singer. Another fact more pertinent to our topic today: Crepe-Myrtle makes a good cut flower for about a day, and then it drops its petals. But it is impressive as the centerpiece in the vase.
The leaves are arranged oppositely on the stem, emerge yellowish-green, bronze or reddish purple (well, that makes it a four season plant) in spring, changing to a nice medium green during the summer and then changing colors in fall. The fall color can be brilliant. Dirr has noted and I concur that generally the white-flowered varieties have a yellow fall color, and the pink/purple/red varieties can have orange, red or purple fall color. So plant a variety of varieties to enjoy maximum fall color.
After the leaves fall, the subtle winter effect can be more easily discerned as the “exfoliating” bark becomes evident. The bark is a gray color, but peels away in blotches much like the Sycamore tree, to reveal cinnamon brown, tan, darker gray or sometimes white. This effect is profound when backed up by evergreens or perhaps a brick wall. Some varieties have more contrast between colors in the bark, but they all provide some interest. This effect takes some years to develop, so patience is required.
Crepe-Myrtles are fairly easily grown, preferring full sun, average soil and little pruning. Prune to shape in summer, but not after August 1st: later pruning results in more winterkill. While this plant is hardy in zones 5-7, it sometimes dies in a late freeze within those climatic zones. By choosing a site wisely, one can forestall the problem.
While there are a few critters and microbes that beset Crepe-Myrtles, I have not had any problems here. Further south, aphids are known to chew on them, and there are acouple of fungal problems that crop up.
Crepe-Myrtles are members of the Lythrum family, Lythraceae. There are about 500 genera within this family, including the Lythrums, Pomegranate and our plant. The Latin genus name of our plant is after Magnus von Lagerstrom, a Swedish merchant and friend of Carolus Linnaeus. Myrtle may have been this man’s wife’s name. (Just kidding: Myrtle is from the two species of plants growing in the Mediterranean region. I’m not sure if the Crepe-Myrtle appellation refers to the French pancake-like treat or the cloth woven from silk. This plant is not related to the Myrtle genus.)
Plant of the Week is a publication of the Marsh Botanical Gardens. Opinions expressed herein do not reflect on the official policies of Yale University. Contact: Eric Larson (firstname.lastname@example.org)
RL’s Warning Note for British Readers: although crepe myrtles are hardy in New Haven to something like minus 25C, I have never seen a good one in England. They may not like our changeable damp, and I think they need hotter summers than we can offer.