Richard Lehman’s journal review – 12 September 2011

Richard LehmanJAMA  7 Sep 2011  Vol 306
952   This is a themed issue on Medical Education, a domain where giant forces compete for the minds of highly selected young people, and science can tell us little about what really matters. I gave my first talk on the subject in 1973, to a largely female student audience in East Germany. My Communist Party minders looked a bit uneasy, but it seemed to go down well with the girls: no doubt they were taken off later for an ideological debriefing. They were told, perhaps, that they were fortunate to live in a socialist democracy where they had been chosen from working class families to carry out a socially worthwhile job which would be paid as well as a steelworker. The people’s government and the Party would see to it that they had the best education and facilities, and that they would be looked after for life. In capitalist countries, by contrast, medical students either have to be financed by their bourgeois parents or incur an enormous burden of debt, which can only be paid off by charging massive fees to their proletarian patients via greedy intermediaries called insurance companies. Now if one of those shifty-looking men could read this article in JAMA, he would feel entirely vindicated: one third of US medical students feel burnt out and/or anxious and the principal correlate is high debt. The next meeting of the Socialist Medical Pioneers will be held on Tuesday evening and all are expected to attend.

978   A great deal of what is important in medicine can be taught to some degree but cannot be measured directly – patient-centredness, diagnostic acumen, good communication, knowing when to leave alone. But there are many technical aspects of practice which can and should be measured, and can and should be taught using technology enhanced simulation. This huge meta-analysis looks at 609 studies relating to a wide variety of technical aids from resuscitation dummies to laparoscopic surgery simulators. In all but a couple of instances, these teaching technologies brought about a marked increase in measures of speed, competence and economy of movement.

NEJM  8 Sep 2011  Vol 365
892   “Being a germ isn’t easy,” according to the first sentence of the editorial on this study of how vancomycin-resistant enterococci became daptomycin-resistant. I think I must demur: being a germ has been easy for about 4 billion years, which is why they rule the planet. And since the primeval soup first produced the beginnings of life, there have never been such exciting places for germs as hospitals. Humans make obeisance to them in paper gowns and masks and latex gloves: how they laugh! Germs, you see, are not individuals: they form aggregated masses like virtual hobbits, sometimes forming biofilms, sometimes living in noses and throats, but mostly liking nothing better than to inhabit the soil. They swap stories and chemicals with each other all the time, and when something nasty comes along, like an antibiotic, they will say to a chum in distress: here, try a bit of this, I’m rather proud of it as a matter of fact, made it myself. And in an hour or two, there are a few hundred billion germs all doing that same thing. Hospitals are so beautiful: warm, generally a bit dirty, full of sick people with lots of other people walking among them, with the very latest in fashionable antibiotic resistance mechanisms. In the case of vancomycin resistant enterococci, however, there had been other nice places beforehand: the faeces of antibiotic-fed cattle cooped up together, for example.

919   Drug-resistant epilepsy is an exceptionally difficult topic, dealt with exceptionally well in this review. Be sure of the diagnosis of epilepsy; be sure of compliance; be sure to refer appropriately; be sure to monitor the patient adequately (though not with drug levels, which are mostly a waste of time); be sure to understand the pharmacodynamics and pharmacokinetics of the agents you use; keep abreast of new drug developments; and don’t forget the place of surgery. There: you don’t have to be all that brainy to be a neurologist.

Lancet  10 Sep 2011  Vol 378
983    Most of the time we give advice and prescriptions to adults with asthma based on symptoms and occasional measurements of peak flow; but nobody would pretend it’s an exact science. This team of Australian researchers decided to use measurement of exhaled nitric oxide instead, and cunningly chose a setting where follow-up would be easy: two antenatal clinics. The mothers with chronic asthma were randomized to either usual care, based on taking a long-acting beta agonist inhaler and adjustment of steroid inhaler by symptoms; or LABA with adjustment of steroid inhaler dose by serial measurement of FENO. The latter group had fewer than half the number of asthma exacerbations. So concept proved: now we need to see how much value this measurement of airways inflammation can have in the management of “brittle” asthma generally, and whether the technology can be developed to make it practical for primary care.

991   “Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in high-income, low-income, and middle-income countries.” says the commentary on this paper about the life-long risk of developing COPD. The investigators did a retrospective longitudinal cohort study using population-based health administrative data from Ontario, Canada (total population roughly 13 million). Great. So where are the data about duration and intensity of smoking and the effects of cessation? Um, not here.

1027 “Chronic obstructive pulmonary disease (COPD) is a major global health problem with a rising incidence and morbidity” begins this review of new therapeutic approaches to COPD. OK, we got you. The three authors then bewail the lack of progress in the field but see possibilities on the future if better biomarkers can be identified and if only the regulatory bodies (FDA, EMA) would just calm down a bit and not demand so much evidence of what actually happens to patients. This is certainly the way to get more drugs on the market: find new surrogate markers and lower the bar of proof. Afterwards discover what happens to hard end-points in post-marketing studies, which take a good part of the drug’s patent-life to get done. Set aside a share of the profits in case things don’t look good and people sue. You know it makes sense. Well, these three authors certainly have reason to think so: between them they have received payments from over 100 outside sources, nearly all of them commercial.

1038   “Chronic obstructive pulmonary disease (COPD) is a chronic disorder with substantial comorbidity and major effects attributable to the high morbidity and mortality rates.” Hmm, nice try, but it doesn’t quite work that way round. Here the discussion is of controversies in treatment, which show how little we know about how to treat COPD once it has started. Debate about inhaled steroids and long-term antibiotics has been simmering or occasionally raging as long as I’ve been a doctor: it’s the authors’ misfortune that the most significant recent study of the latter appeared in the NEJM just two weeks ago. As for the use of beta-adrenergic agents, the tables suddenly turned when a recent BMJ study showed that beta-blockers conferred a survival advantage: though the effect size is probably 6%, not 25% as claimed. Enough: in the overwhelming majority, this is a disease of smoke. Get rid of tobacco, domestic dung fires and atmospheric pollution, and chronic obstructive pulmonary disease (COPD) will no longer be an important cause of morbidity and mortality in high-income, low-income, and middle-income countries, to coin a phrase.

BMJ  10 Sep 2011  Vol 343
Ever heard of J Alison Glover? I can’t say I had until I read Jack Wennberg’s indispensable book, Tracking Medicine, a few months ago. Now Alison has a long pedigree as an English girl’s name, as you will know it you have read the jaunty poem from Harley MS 2253 (compiled c1340) with a refrain that ends
From alle wymmen my love is lent
  And lyht on Alysoun.

But this is merely to warn you that our J. Alison is a man. His father was called James Grey Glover, so he really has no excuse for adopting this egregious name. We cannot even justify leniency on grounds of American origin, because JA Glover was an Englishman who trained at Cambridge and Guy’s. First rate shot too. In the 1930s, he investigated the end-results of adenoidectomy and tonsillectomy among English schoolchildren, and concluded that although rates of T&A removal varied to a spectacular degree around the country, outcomes didn’t vary at all. Now here is a Dutch trial of the effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections, carried out 80 years later. And do you know what? It doesn’t make any difference at all.

Gender differences (which used to been known as sex differences, until that was thought to cause confusion) are very pronounced in ischaemic heart disease. Here four female professors of medicine and an associate carry out a complex modelling exercise to explore the trends, based on whole-population mortality data from England, Wales, and the USA. I can’t say that I altogether follow their argument, but if it is to be believed, then the idea that female IHD accelerates following the menopause is a myth. Instead, IHD in young men shows such an acceleration. As for the progress of women in cardiology: well, in my day, there weren’t any, and now you there are, oh, dozens.

Whatever you (or I) may say about the research papers in the BMJ, the Clinical Review section does great work for British doctors who want to stay up to date with basic clinical skills and knowledge, and for others around the world who either pay a subscription or can get full text via HINARI. Here is a good general guide on how to assess and investigate cognitive impairment in the elderly: the authors mention some alternatives to the Mini Mental State Examination, which is subject to copyright, but don’t include the CASE instrument developed by an Ottawa team, which has good claim to be the best validated, and is freely available on line (as it jolly well should be).

Ann Intern Med  6 Sep 2011  Vol 155
281   Open bariatric surgery can take several forms, including gastric bypass and duodenal switch. As we’re in historical mood, it’s worth noting that the surgical foundations of these procedures were laid down by the great Viennese surgeon Theodor Billroth not long after abdominal surgery first became possible in the middle of the nineteenth century. Billroth was also an excellent musician and a warm and generous friend to Brahms, but after many years the curmudgeonly old composer took umbrage over some minor affronts and poor Billroth was left hurt and puzzled (Here is a superb old paper about this). What was hazardous major surgery in 1867 remains hazardous major surgery in 2011. This outcomes study from a fairly small case series in Norway and Sweden shows that biliopancreatic diversion with duodenal switch is the more effective procedure, but also the more hazardous, with a 62% rate of adverse effects over 2 years, and 16 readmissions in a group of 29 subjects.

292   So there’s a global epidemic of type 2 diabetes upon us and we want to know what to do about it. This cohort study shows how it can be done. The National Institutes of Health (NIH)–AARP Diet and Health Study cohort was established in 1995 to 1996 by the National Cancer Institute and ended up following more than 200,000 American adults. Those who kept their BMI under 25, took 20 minutes of exercise 3 times a week, drank alcohol regularly, did not smoke and kept to reasonable diet of some kind (there is a black box area here) had 16% of the chance of developing diabetes compared with those who did none of these things.

Plant of the Week: Hydrangea paniculata “Tardiva

Wandering the streets as autumn approaches, both in New England and in old, there are few shrubs worth a glance, but this is a valuable exception. A well-grown bush is a lovely thing, with wide lobular leaves and a profusion of huge conical flower heads. They start green, remain a pure white for a week or two, and then fade to pink and brown. Bees like them, and if you push your nose close enough you may detect a slight scent of grass and honey.

Every garden should have a variety of this plant suited to its size, to keep company with repeat flowering climbing roses of pink, red or apricot, and those dark-coloured Polish clematis hybrids which seem to go on flowering for ever.