Richard Lehman’s journal review – 30 August 2011

Richard LehmanJAMA  24-31 Aug 2011  Vol 306
840   Every GP knows that some patients who are admitted to hospital come out without their usual medication and take this as an indication that they don’t need it any more. This happens particularly after admission to ICU. The team doing this cohort study in Ontario makes an attempt at quantifying what effect this might have in terms of death plus readmission: nothing reaches statistical significance but it’s interesting to note the tendency towards harm from stopping statins and aspirin and the tendency to benefit from stopping respiratory inhalers in this largely elderly group with chronic illness. Somebody needs to repeat this natural experiment as a properly powered RCT by taking all older patients with comorbidities off their steroid, beta-adrenergic and anticholinergic inhalers and replacing them with identical-looking placebos and looking at mortality and hospital admission. Or maybe we’re already past the point of equipoise – we already know that these puffers increase rates of infection and total mortality for most adult groups; and yet we carry on prescribing them by the bagful.

856   It’s amazing what happens in diastole: valves open and shut and oxygenated blood floods into the left ventricle and the coronary arteries, while the right heart fills with venous blood from the rest of the body. Then in half a second or less it all goes into reverse. Arterial blood pressure zooms down and then back up again, creating a characteristic pressure wave which is modified by the elasticity of the arterial wall in the greater part of the arterial tree. Gradual stiffening of the heart and the arteries can lead to heart failure with preserved systolic function: this is not synonymous with diastolic dysfunction though the two often go together. To fully understand why so many old people – especially women and people with diabetes – slowly develop this kind of “heart failure” you would need to do long-term sequential measurements of their pulse pressure, their arterial elasticity, their levels of natriuretic peptide, their coronary perfusion and their indices of diastolic LV filling on echocardiography. I once thought of doing such a study but concluded that it would be of little benefit: by the time you have heart failure, your heart is failing. This cohort study from Olmsed County just looks at the cardiac events in diastole and concludes that an early restrictive filling pattern does herald deteriorating function and the development of overt failure over 4 years.

NEJM  25 Aug 2011  Vol 365
689   In the days before chronic obstructive pulmonary disease existed, we used to call it chronic bronchitis and would often treat it with continuous antibiotics through the winter months. But from about 1980 onwards, such primitive strategies were increasingly frowned upon, and instead these unfortunate victims of smoking were given all sorts of beta-stimulants, theophylline derivatives, inhaled steroids and inhaled anticholinergics, as noted above. Now we have come full circle with a trial of daily azithromycin for 12 months in addition to usual care for COPD. This reduced exacerbations by a quarter and improved quality of life. As the authors note, we don’t know what effect such a strategy, widely employed, would have on patterns of respiratory bacterial resistance. But I think the greatest benefactors to pulmonology (as it is called over here) will be the people who invent new antibiotics – though the old ones are still good enough for most purposes – and new ways to help people stop smoking.

699   Apixaban is a coming drug. You know what it does – come on, think. Xa-ban: it blocks Factor Xa, it’s oral, and it’s fixed dose. So one day soon you will be prescribing it instead of warfarin. But it does make people bleed, of course, especially when combined with an anti-platelet drug. The APPRAISE-2 trial was designed and sponsored by Bristol-Myers Squibb and Pfizer in the hope that it would reduce recurrent ischaemic events if given after acute coronary syndromes together with aspirin or clopidogrel: but it didn’t, and the trial was stopped early due to the increase in major bleeds. Not that B-M S and Pfizer will mind all that much: this drug and the other xabans (and also the direct thrombin inhibitors) all have an enormous potential market already.

Lancet  27 Aug 2011  Vol 378
771   It’s old news, but it’s good news: tamoxifen given for 5 years for oestrogen receptor positive breast cancer in postmenopausal women reduces recurrence by one third. This is the very robust conclusion of an updated meta-analysis of 20 randomized controlled trials. Overall non-breast-cancer mortality was little affected, so this drug has saved a lot of lives.

785   Biochemical screening in the newborn is generally such a success that nobody questions it; even me. And we all diligently carry out physical examination of the newborn at 48hrs and 6 weeks; even me. But despite these examinations and routine antenatal ultrasound for cardiac defects, a lot of time-critical congenital heart disease still gets missed. This Birmingham trial looks at whether we could do better by using routine pulse oximetry for the newborn, taking oxygen saturation measurements at the hand and the foot. To me, a screening sceptic, this paper makes a good case for universal pulse oximetry screening. I am surprised the accompanying editorial isn’t more enthusiastic. In study conditions, the sensitivity was 99% and testing also detected other kinds of critical illness in 40 out of 20,000 tiny new babies.

BMJ  27 Aug 2011  Vol 343
Actually there is no print issue of the BMJ bearing this date, but to flesh out what is an exceptionally lean week, I’ll talk about two papers which have just appeared on the website.

All doctors have a slightly uneasy relationship with prognosis in cancer: it’s hard to break bad news, and most of the time we are wrong if we attempt even the vaguest time frame. There is a strong movement within palliative care which argues against prognostication on the grounds that it is a distraction: the message this movement promotes is that if you wouldn’t be surprised if the patient died in the next year, you should call in palliative care. All very well, but how do you put that to the patient, especially if the diagnosis is not cancer? But I digress: the patients in this study did have cancer, and the investigators sought an “objective” set of criteria to predict death within days, weeks, or months, which would be better than the judgement of individual clinicians. They claim to have done this here, with quite complex instruments, one of which incorporates blood tests. They’re still wrong 40% of the time.

A fascinating study of the types and progression of headache over 30 years among the worthy burghers of Zurich. It was while looking across the many clocks of the city that Albert Einstein first conceived the notion that time could be relative rather than absolute. Now if I had an idea of such grandeur I would inevitably pay for it with a migraine with aura, as I get these with great frequency (though not great severity) whenever I exert myself mentally – and of course hardly a day goes by without my reformulating the basic laws of the Universe. It’s actually relatively uncommon for a man to get migraines with aura and to keep them for life. Only 20% of people who get migraines keep on getting them for more than a few years, and most of them are without aura and occur in women. People’s headaches tend to vary through life, at least in Zurich – a place, one would have thought, as free from anxiety as any on earth.

Plant of the Week: Albizia julibrissin

I remember being seized with a desire for this plant many years ago, when I caught sight of it in a book on trees and shrubs designed to straddle the British and American markets. Now such straddling can often be cheating: I don’t think there can be any two places in the UK and the USA which have truly similar weather conditions. American seasons follow a continental pattern, even on the sea coasts. Summer is hot and sunny; winter is cold and snowy. You know where you stand.

Now the silk-tree, which comes from Iran, is a plant that likes to stand in hot sunshine for several months of the year. Then it will be perfectly ready to stand in frost and snow for the other half. It has lovely ferny pinnate leaves and the most beautiful and unusual tufts of pink silk for flowers – hence its common name. It bears itself graciously and is covered with flower in New Haven CT from early July to late August and looks set to carry on. Whether it ever flowers in the UK I am unable to say. It is certainly offered for sale in English nurseries, but I suspect the only time you will see the silken tufts is on the plant label, and perhaps during an occasional freak British summer featuring prolonged warmth and sunshine.

This small tree gets its bizarre name from the Italian nobleman Filippo degli Albizzi, who first introduced the Persian species to Europe, and from the Farsi gul-i-abrisham, meaning flower of silk. I have only seen a walled garden in Iran during the winter months, so I don’t know if the gul-i-abrisham flowers there: I imagine so, among the cypresses, almonds and pistachios and neat terraces of bedding plants grown along carefully maintained water-courses. A place of this sort was known in ancient eastern Iran as pairi.daêza and associated with the Zoroastrian heaven, or Place of Song. The word has come down to us as paradise.