Richard Lehman’s journal review—20 August 2012

Richard LehmanJAMA  15 Aug 2012  Vol 308
681   From time to time, most of the medical journals are seized with a worthy impulse to discuss violence. One of its commonest and most ubiquitous forms is intimate partner violence, most of which goes undetected. Occasionally it is first disclosed in the course of a medical consultation, and for decades doctors have been upbraided for not being more proactive in detecting it and offering women sources of help. There is a reasonable assumption that this will result in better quality of life for women; and like all reasonable assumptions, this needed to be demonstrated in a randomised controlled trial. In fact this RCT of a screening intervention in 10 Illinois primary care centres did not show any benefit in the course of 12 months. Nearly 15% of women had experienced partner violence in the previous year, and those provided with materials about sources of help used them twice as often as those who weren’t given the supportive material; but this kind of screening did not improve QOL in the short term. Perhaps this needs revisiting in a few years.

700    Post-traumatic stress disorder is a burden that can be hidden or shared. Many of the post-war generation preferred to hide it, even from their partners. Coming home from Burma, or a prison camp in Germany, or from forty heavy bombing missions, they would wake screaming in the night thirty years later but never tell their wives why. I am sure it took its toll on relationships in all sorts of other ways too, and still does. This small trial compared cognitive behavioural therapy for couples where one partner has PTSD with “wait-list” for therapy (i.e. nothing—or what might be called British Cognitive Therapy). Those who had the immediate intervention showed fewer features of PTSD and better relationship quality.

Arch Int Med  13/27 Aug 2012  Vol 172
1133   The valley of the shadow of death is a place we would rather not enter, but as doctors, it is our job to go there with our patients. In this study of Factors Important to Patients’ Quality of Life at the End of Life, the most important factor is a person whose rod and staff are at their side to comfort them. “These results suggest that physicians who are able to remain engaged and ‘present’ for their dying patients—by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings—have the capacity to improve a dying patient’s QOL”. The other person who can fulfil this function is called a “pastor” in this American paper, or what we would call a hospital chaplain. You don’t have to have personal religious belief to recognize the importance of such people to the dying. But ours is a secular vocation that stretches throughout life: as Edvin Schei puts it this way at the close of his great essay on Doctoring as Leadership:
“Crucially, clinical leadership needs to be carried out in ways that convey self-awareness and intellectual humility, thereby “humanizing”  the physician, strengthening the patient’s dignity as a co-subject, and turning the relationship into a real encounter of mortals.”

1145    The only piece of information about coronary stents that has stuck with me over the fourteen years that I have been reporting about them is that bare metal stents are perfectly good for most purposes, except where there is a high risk of stenosis, in which case drug-eluting stents (DES) have a marginal advantage. This does not vary much between the various drugs eluted, but it is very important for patients to take daily clopidogrel for at least a year afterwards. In the USA, it is quite common to put drug-eluting stents into people who cannot afford the cost of clopidogrel, which means that their rates of immediate restenosis are actually higher than if they had bare metal. This study concludes, ”Use of DES in the United States varies widely among physicians, with only a modest correlation to patients’ risk of restenosis. Less DES use among patients with low risk of restenosis has the potential for significant cost savings for the US healthcare system while minimally increasing restenosis events.” Who knows: in the wonderland that is American interventional cardiology, it might even reduce them.

1162    This is the week we need to think hard about how to treat blood pressure. In a patient over 65, for example, what should you be measuring? Yes, the systolic. OK, the diastolic too. The pulse pressure—yes, good, that predicts heart failure without systolic dysfunction. But what about the walking speed? This intriguing study from a NHaNES cohort shows that an elevated SBP is associated with increased mortality in fast walkers alone among the elderly; among slow walkers neither DSB nor SDB predicts mortality, and among those who could not complete a walking test, high BP is a very strong predictor of reduced mortality.

NEJM  16 Aug 2012  Vol 367
595    I have spent years railing against PSA and its Perfectly Stupid Attributes as a screening test, so I was peeved to see yet another article on prostate-specific antigen screening appear as top bill in this week’s NEJM. But it deserves its place, because this paper marks a long-overdue move away from the herd approach to screening towards a quantification of individual quality of life calculations. We know that whole population screening using PSA can reduce mortality from prostate cancer without any great effect on total mortality, and that it leads to a huge rate of overdiagnosis with attendant further investigation and unnecessary surgery. But what of the individual’s choice in the matter? Men may place very different values (known as “utilities”) on different outcomes such as sexual and urinary dysfunction and the risk of this particular form of death. Here at last are some simulation models that allow shared decision making with individuals, based on data from the European Randomized Study of Screening for Prostate Cancer (ERSPC). You still have to be numerate with a lot of time on your hands to work your way through, but it is a step in the right direction, as Hal Sox discusses in a very good editorial.

616   Last week this journal published two Pfizer funded trials of tofacitinib, an oral drug which inhibits Janus kinase activity. You’ll remember that the drug is associated with an increase in infections, possibly due to lowered neutrophil counts, and with increases in LDL-cholesterol, when taken long-term to suppress rheumatoid arthritis. In this trial, it was used to suppress active ulcerative colitis over a period of 8 weeks, compared with placebo. It took 52 centres in 17 countries to recruit 194 patients; at the optimal dosage, about half showed a useful clinical response. All the caveats I raised last week apply—the duration of the trial, the placebo comparator, and the domination of the design and reporting by the manufacturer which in this case extends to a confidentiality agreement with the authors, whose conflicts of interest have to be sought for on the website. This is such an absurd way to determine the real efficacy and safety of drugs which may end up being given to hundreds of thousands of human beings at great cost. At least if Pfizer applies for a European licence for this drug, we may get to look at an adequate set of individual patient data from the European Medicines Agency—stretching for all of 8 weeks.

625   Stroke and Bleeding in Atrial Fibrillation with Chronic Kidney Disease is another nice Danish national registry study which shows exactly what you might expect: “Chronic kidney disease was associated with an increased risk of stroke or systemic thromboembolism and bleeding among patients with atrial fibrillation. Warfarin treatment was associated with a decreased risk of stroke or systemic thromboembolism among patients with chronic kidney disease, whereas warfarin and aspirin were associated with an increased risk of bleeding.” But nowhere in this study could I discover what they were actually talking about. “Chronic kidney disease” is a term now applied to anyone with an estimated GFR less than 60, meaning over 10% of the population; and by the same token it is a continuous variable. Here the authors state that 2.7% of their sample had “non–end-stage chronic kidney disease.” Yes, yes, but what does that mean? The sun is coming out, there is gardening to be done, and I am fed up with searching for information which needs to be in the first section of the summary.

Lancet  18 Aug 2012  Vol 380
651   An effective and well tolerated treatment that reduces the risk of asthma exacerbations in patients with severe eosinophilic asthma. That wouldn’t be advertising copy, now would it? Of course not, it is the conclusion of the abstract of this Lancet paper describing a trial of mepolizumab called DREAM—a dream come true for GlaxoSmithKline, who will no doubt be eager to buy up reprints of this paper. And perhaps that is all fine and dandy, because everybody may need to be told that this antibody against interleukin-5 really does reduce asthma severity in adults with high sputum eosinophil counts. However, it has to be given by injection and may yet have effects that we know little about, apart from the risk of depleting health service budgets.

660   Now all gather round and look at this. It is an example of a randomised controlled trial as it should be done. OK, it has a silly acronym: now stop carping, and EMBRACE the message. A good trial addresses a good clinical question, and whether regular azithromycin reduces exacerbations in non-cystic fibrosis bronchiectasis is a good question. A good intervention will have a large effect and will not require large numbers of trial participants: here there were 71 in the treatment arm and 70 controls, all recruited from just 3 centres in New Zealand, so keeping down costs and helping to ensure consistency. The trial was publicly funded and there were no conflicts of interest. The end-points were clinically relevant and are all well described and tabulated, with caveats where necessary. Numbers needed to treat are not given but can be calculated with reasonable ease. A trial like this, of a cheap intervention of known long-term safety in an important, well-defined clinical group appears about once a year in a leading medical journal: enjoy. Oh, and by the way, it works.

668    But to do the greatest good to the greatest number, the best route is always to remove harm. We have removed smallpox; we can prevent most important infectious illnesses, and cure most of the rest; surgery is safer than it has ever been; we have sewers and traffic safety laws; our food and water are largely free of contamination. We want these to be human rights for everybody; but there is no sign of concerted world action to end the sale of tobacco. Here’s a global survey of smoking among 3 billion individuals. It makes you want to scream. The official commerce of addiction and death seems beyond control in most nations, and on a global scale, it is thriving.

BMJ  18 Aug 2012  Vol 345
The prevention of falls in the elderly is a subject that crops up so frequently that it probably has its own journal by now. Here’s a trial from Sydney of integration of balance and strength training into daily life which achieved a 30+% reduction in the fall rate by training the old cobbers to practice strengthening and balance manoeuvres throughout the day as the opportunity presented itself. I’m not sure whether the authors are boasting about their programme or about the resilience of the elderly Australian when they report that “a LiFE participant was diagnosed with a pelvic stress fracture and attributed this to increased walking and stair climbing, but continued on the programme.”

Pay for Performance will always cause harm, which Paul Glasziou and colleagues neatly summarize as attention shift, gaming, and loss of motivation. The question is whether it ever has any benefits to outweigh the harms. I am a total sceptic these days: I think QOF should be abolished and nothing should take its place. But Paul as usual is calmer and more nuanced, and the subtitle of his piece is “How to make it worth doing.” My answer would be through professionalism, patient-centredness, and well-focussed audit cycles, leaving the money out completely.

The high standard of BMJ clinical reviews continues with an excellent piece on the diagnosis and management of peripheral artery disease. Thanks to the efforts of the tobacco industry, PAD will continue to flourish throughout the developing world. The BMJ should do its bit by removing its paywall and making these clinical reviews a standard source of high quality, unbiased information in countries such as China (288 million smokers), India (100M smokers), and Russia (31M).

Plant of the Week: Anaphalis triplinervis

This species of “pearl everlasting” is sold in a variety of forms and cultivars, the commonest being “Sommerschnee” which has silvery leaves and is said to need sunshine. We have it growing along a shaded road edge where it has thrived imperturbably for 15 years without much light or any feeding.

This is the kind of plant that every garden needs. And we are even fonder of its straggly sister, which has longer stems and thin green leaves and a profusion of tight pure white daisy flowers. These remain attractive for months and form a perfect foil for the blues and oranges of the late season. A really essential plant for the autumn garden.