Richard Lehman’s journal review – 14 November 2011

Richard LehmanJAMA  9 Nov 2011  Vol 306
1983   Replumbing the brain through a hole in the skull is an idea that sounds straight out of the heroic days of kill-or-cure surgery. It’s been known for about 50 years that you can connect the superficial temporal artery branch through the cranium to a middle cerebral artery cortical branch, and so restore the middle cerebral blood supply if it is impaired, usually as a result of carotid artery stenosis. You can imagine old Harvey Cushing devising this operation in his glory days at Yale, except that he didn’t. There was a big trial in the 1980s which failed to show any benefit, but this new trial tested the possibility that with modern brain imaging it might be possible to identify a high-risk subgroup of people who might benefit from the procedure. Advanced PET imaging was used to select the patients with impairment of cerebral blood supply who would be most likely to suffer stroke. However, the trial was stopped for futility once the two-year results for 194 participants were analysed: surgery plus medical therapy prevented no more strokes than medical therapy alone.

2011   Generally speaking, it is best not to meddle with the cerebral circulation, but in the case of people with arteriovenous malformations in the brain, it may be necessary. Then it becomes a question of whether to lift the cranium and do microsurgery, or to try and ablate the malformation, using stereotactic radiotherapy or by introducing an embolizing device. This systematic review shows a diminishing case fatality with time but a wide spread of results in individual trials. Overall, the rates of permanent neurological deficit or death vary little between the three modes of treatment, at 5-8%.

2022   Giving a “Grand Rounds” talk at the department of Internal Medicine at Yale the other week, I used several video clips of patients speaking and was reminded of how powerful a tool this can be. In fact I’d go so far as to say that no talk about anything connected with what patients think, need, or experience should ever be given without a few clips chosen from the endlessly rich collection on It’s the product of more than ten years of careful, open interviewing and thematic selection: it’s there to show the full range of patient experience, not to illustrate anyone’s public polemic. But here is an opinion piece from the USA (which has no such collection) suggesting patient videos should be used to give emotive weight to public health messages, such as MMR vaccination. I do hope this never happens. In the adversarial culture of American medicine and politics it seems almost inevitable that it would lead to highly publicised “clip wars.” That is exactly what the late, great Ann McPherson strove to avoid when she set up her visionary DIPEx project in 2000: she wanted all patients to have a voice, not to be set shouting at each other.

NEJM  10 Nov 2011  Vol 365
1763   Have you ever eaten fenugreek sprouts in Germany? If you have, it is possible that memory may have blotted out the experience; or else that some soup, modge, stew, or salad that you politely made your way through might have contained the sprouts without your being aware of the fact. These are ever-present dangers with German cuisine; moreover, it seems that even the Germans themselves can suffer from sprout amnesia. During the epidemic of Shiga toxin-producing E coli that affected Germany in May this year, sufferers were naturally urged to try and recollect the foods that they had eaten prior to becoming ill: 88% remembered eating cucumber and 25% remembered eating fenugreek sprouts. But at the end of one of the most intensive public health investigations ever undertaken, the culprit in every case was found to be fenugreek seeds. Most unfortunate sufferers had chosen to eat at a restaurant where no fewer than half the dishes were garnished with fenugreek. Don’t believe studies that depend on people’s recollected food intake.

1771    The brief German epidemic affected 3816 people, of whom 54 died. The epicentre was Hamburg, with two other small restaurant-based clusters to the south. This paper will become an instant classic of the epidemiological literature: a John Snow-like E coli map of Germany combined with modern bacterial genomics and an account of the clinical course of the worst affected patients. The accompanying editorial tells the story of how the epidemic may have begun with contaminated fenugreek seed from Egypt in 2009: fascinating and well worth trying to access.

Lancet  12 Nov 2011  Vol 378
1699   A cluster randomised trial from Australia looks at some of the components that might constitute good acute stroke care. Unfortunately it combines three interventions – swallowing assessment, fever control, and blood sugar control – which may or may not be of equal importance. Deliver all three interventions and you can achieve a 15.7% (95% CI 5.8-25.4) reduction in death and dependency at 90 days. The editorial describes this as “dramatic” but goes on to wonder which of these measures is really important: for example, a swallowing assessment before giving oral food or drugs is generally accepted as essential, but was achieved at less than the normal UK level even in the intervention group. You may wonder if giving paracetamol for fever, and fluids for mildly elevated blood glucose, really add all that much. And perhaps the greatest improvement in results was due to none of these but simply the closer coordination of care in the intervention group.

1707   It’s good to see the Oxford clinical trials support unit putting its efforts to good use in this meta-analysis of individual patient data from 10 801women who received radiotherapy following breast conserving surgery for cancer. I can hardly do better than to quote the conclusion of the abstract: “After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made.” That really is good news. The CTSU should focus its efforts on studies of this kind rather than attempts to promote HDL-C-raising drugs for pharmaceutical companies.

1727   It’s interesting to compare and contrast the two Seminar pieces this week – the first on non-small-cell lung cancer and the second on small-cell lung cancer. The latter condition – called “oat cell cancer” when I first walked the wards, scarcely pausing at the bed of an emaciated old man with clubbed brown fingers – is still generally lethal, and all the seminar can do is describe regimens of chemotherapy which might mean a life expectancy of 6 rather than 3 months. With non-small-cell cancer, though, we are dealing with range of different tumours with varying genetic characteristics, which is why I get impatient with the term. Fortunately it seems likely that with better characterisation will come better treatment, which may even be curative. Horton’s question “why has the gene revolution failed so spectacularly to deliver anything tangible for patients?” may apply to most population-wide SNP hunting but doesn’t really apply to cancer genomics, where scientists are looking at the genes of cancer cells to devise new ways of killing them. In fact this area may be seeing the growth of a new kind of open drug development not seen since the days of penicillin and Florey, Chain and Heatley:

BMJ  12 Nov 2011  Vol 343
The formidable list of authors at the head of this systematic review of referral to exercise programmes in primary care includes four professors with “exercise” in their titles, so I was worried that this might be the equivalent of setting on the Vatican to do a systematic review of the benefits of regular confession. But no: it makes it all the more startling that they are forced to conclude that “Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.” That’s not to decry the value of exercise itself, of course: it just needs to be part of a daily routine together with working, eating, drinking and sleeping.

Another first-rate qualitative study here in the BMJ research pages: interviews with 28 men from the West Midlands who had undergone surgery for colorectal cancer. Most of them were experiencing erectile dysfunction as a result, though none of them had been warned to expect it. This reminds me of Jack Wennberg’s pioneering work in the USA in the 1980s, when he was examining informed patient choice in surgery for benign prostatic enlargement. Some men feel suicidal at losing sexual function, most find it traumatic, whereas for a few it matters little. This single study, consisting of simply talking to patients, is all that should be needed to show the urgent need for proper sexual advice to patients about to undergo colorectal cancer surgery. I hope that in a few years it will be seen as a key example of how studying the patient experience can be used to improve patient care.

Plant of the Week: Prunus subhirtella var. Autumnalis by Eric Larson 2008

This time of year it’s hard to find things blooming in the landscape. Difficult but not impossible. For instance, Dandelions (which have been promoted on this page in years past), a few struggling Cosmos, a few Roses, Chrysanthemums of course, some species and hybrid crosses of Witch-hazel, the fabulous Camellias, Winter Jasmine and others. If you have something blooming or reblooming in your landscape, email me back and let’s talk about it.

Autumn –blooming Higan Cherry is a variety, or naturally occurring variation of the species, kind of like a redhead in human terms. The species is one of about four hundred thirty within the genus, and they are naturally occurring throughout the temperate regions of the northern hemisphere. The genus name derives from the Latin name for the Plum Tree. I could not find an etymological source or meaning for “subhirtella.” So this is another reason for a return e-mail from an astute reader. The genus has traditionally been included in the Rose family, Rosaceae as a sub-family, Prunoideae. Some botanists have carved out a separate family, Prunaceae (or Amygdalaceae). The genus includes Plums, Apricots, Peaches, edible and flowering Cherries and Almonds. The Higan Cherry is native to Japan. The Weeping Cherries are usually the weeping form of the Higan Cherry grafted onto another rootstock.

The species grows to a height of about forty feet tall, with a spread of about half or two-thirds of that. While the weeping form tends to not get that tall, the Autumn-blooming Cherry will approach that. The Autumn-blooming Higan Cherry will bloom sporadically in fall after leafdrop, especially with the warm weather we’ve been having. Then in spring before the leaves emerge, it will bloom more fully, providing two seasons of bloom, which is rare for small flowering trees. The buds are deep pink, giving way to soft pink and gradually aging to an almost pure white. Autumnalis flowers are semi-double (10 petals) and about one-half to two-thirds of an inch across. The subtle sporadic pink flowers of Autumn-blooming Higan Cherry would go nicely in an enclosed courtyard, against an evergreen background or perhaps beside a brick or dark-colored stone wall. The tree likes full sun to partial shade, a well-drained average garden soil and will require little or no care as regards pruning or pest control.

Note by RL: A wonderful tree but liable to bacterial blight in damp England, like all Prunus spp.