Richard Lehman’s journal review – 6 August 2012

Richard LehmanJAMA  1 Aug 2012  Vol 308

465    Living with heart failure is a miserable business, and about 40% of patients with this label are clinically depressed. This is due to a complex mix of factors: the biochemical “feel-bad” factors alone are too complex to list here, and they come from every system in the body, not just the left ventricle. Small wonder that depression in heart failure is associated with physical deconditioning and increased mortality.

This study recruited 2322 subjects with systolic heart failure and depression from the USA, Canada and France and randomised them to an exercise programme or guideline-based care. At a median follow-up of 30 months, two-thirds of both groups were dead – these people really did have failing hearts. Survivors from the exercise group had slightly lower depression scores. The authors admit that this may be of little importance in the greater scheme of things. I would suggest that this study is one more illustration of the fact that people with heart failure and depression are in the final trajectory of their lives, and badly need the supportive and palliative care that so few of them can currently access.

475    The heyday of coronary artery bypass grafting is over, but I don’t see any end to the bickering over detail: off-pump or on-pump, arteries or veins, or if veins, harvested by endoscope or through a long incision. This careful registry search shows that on the last point, honours appear to be equal, in terms of mortality and revascularisation, and using the endoscope leads to fewer immediate wound complications at the harvesting site.

493    The name of John Taylor will live forever in the annals of musical infamy, for he was the cataract surgeon who managed to blind Handel and kill JS Bach. But cataract surgery in our century is simple and safe, and does more good than you might be aware of. This study shows that it reduces the rate of hip fracturesor at least it probably does, since this is an observational study of Medicare patients with a record of cataracts who did or did not opt for surgery. Plenty of room for confounding, therefore; but it makes sense that you trip over fewer things if you don’t have a blurry blob in the front of your eye.

502   This week The Rational Clinical Examination series asks the question, Does This Adult Patient With Suspected Bacteremia Require Blood Cultures? At first I rubbed my eyes and muttered “like, duh…”, but the article does make a strong case for not rushing into this investigation, which has a false positive rate of 50% and can lead up all sorts of expensive blind alleys. Definitely worth reading if you are the kind of doctor who goes splurging blood into bottles of broth: consider the pre-test probability, and think twice.

NEJM   2 Aug 2012  Vol 367

399, 411, 423  Three papers in this week’s NEJM deal with the question of drug prophylaxis against HIV infection in heterosexual populations. Tenofovir based regimens definitely have an effect in the three African populations studied: I then tried to understand how this might play out as a preventive strategy by turning to the editorial on p.459. But I’m afraid I left off in bafflement, convinced that nothing short of a universally effective vaccine will ever rid Africa and the world of HIV. There is fuller discussion on p.462 as well, with more detailed consideration of clinical scenarios where HIV prophylaxis might be needed.

Here are the links:

Lancet  4 Aug 2012  Vol 380

475    Like everybody else, I would really welcome the arrival of lots of new drugs to treat type 2 diabetes. I’m easily carried away by the optimism that surrounds the introduction of each new drug class, such as the gliptins or dipeptidyl peptidase-4 inhibitors. For all we know, these blood sugar lowering agents may be a real advance on the sulfonylureas we currently tend to use as second-line treatment. This trial comparing linagliptin with glimepiride shows that it lowers glucose by about the same amount, and with less risk of hypoglycaemia. But what of its long-term safety? And what effect does it have on the vascular events which are the main reason for treating diabetes? This trial was not designed to tell us about these, and we will simply have to wait for longer and bigger trials. In the meantime, each time you use a drug in this class, you are carrying out an experiment, and you have an ethical responsibility to tell your patient that you don’t know whether your treatment is going to be either safe or beneficial.

484    This study of duration of antibiotic treatment for acute pyelonephritis in women is described as having taken place at “21 centres of infectious diseases in Sweden”. I’m not quite sure what that means: all the women I have ever seen with acute pyelonephritis have turned up in primary care with fever, flank pain and tenderness, dysuria and a dipstick positive urine sample. I’ve never referred any of them to a centre of infectious diseases, in case they caught something, and I’ve generally treated them with 7 days of ciprofloxacin 500mg twice daily. According to the Swedes, that’s correct: this study shows that a further week of cipro makes no difference.

491   Can poliomyelitis be eradicated by the end of next year? Theoretically, there is nothing to stop this happening (see editorial, p.454), but everything depends on uptake of polio vaccine, and this is currently falling in Pakistan and southern Afghanistan. There are hints that this may be due to the use of polio vaccination as cover for locating bin Laden. While that isn’t mentioned explicitly here, it certainly cannot have helped what is already dangerous work.

BMJ  4 Aug 2012  Vol 345

One of the biggest perceived barriers to smoking cessation is the fact that most people gain weight after quitting. This meta-analysis offers no comfort at all: it shows that the mean weight gain is 4-5kg and most of it happens within 3 months. Most people find it difficult enough to overcome nicotine addiction and the thought of gaining 10lb in a few weeks is hardly encouraging. It would be useful now if somebody could do a further meta-analysis to see if particular smoking cessation treatments can prevent some of this weight gain.

Inhibitors of angiotensin converting enzyme are also inhibitors of bradykin breakdown, so there is no such thing as an ACE inhibitor that does not increase coughing, especially during episodes of respiratory infection. Many people give up taking ACE inhibitors for this reason, but those who persevere are rewarded by a reduction in pneumonia, as demonstrated in this Portuguese systematic review. This effect is largest in observational studies carried out in Asia, and it is not seen with angiotensin receptor blockers, which have no effect on bradykinin breakdown.

Speech therapy following stroke has no effect on speech recovery. The clear result of this Manchester trial will come as a blow not just to speech therapists but to many stroke sufferers and their families. Speech therapy is really supportive therapy, a token that society cares and is trying its best. The evidence here shows that you could take it away with no effect on speech, but that would leave people feeling that nobody was doing anything. And we disparage this kind of “futile” care at our peril: a lot of what we do as doctors falls in the same category. The difficult trick is to preserve this ability while remaining honest with ourselves and our patients.

Plant of the week: Campanula “Swannables”

We found this gem at our favourite nursery a couple of days ago – a lovely plant of trailing habit with abundant large bells of greyish lavender-blue. Gerald Sinclair, owner of The Nursery Further Afield, praised it mournfully as the rain beat down on our bare heads, and eventually allowed us shelter in his shed. “I never let the public in here, but you’re not the public” he said; but when we asked about another plant, he suddenly changed his mind and shooed us off to take shelter in our car.

Like all true nurserymen, Gerald is very reluctant to sell his produce, rightly fearing that it will come to grief as soon as it has left his gentle care. But I am optimistic about Swannables: most campanulas of this size look after themselves quite well, and slugs usually avoid them. We shall see. Gerald will not mind if we return to report its death: it will prove his point that people cannot be trusted with his plants, and that the world is so arranged that most of the best plants die anyway.