Richard Lehman’s journal review—28 August 2012

Richard LehmanJAMA  22-29 Aug 2012  Vol 308
777    A new stent from Switzerland! Don’t all leave the room at once. Sit down and make yourselves COMFORTABLE while I tell you the story of poor little Bi, who got parted from the rest of the Olimus family early on in life and remained lonely and stranded in Europe. Meanwhile, her brothers and sisters Sir, Zotar, Ever, and Tacr were leading a high old life in America. How could poor little Bi Olimus ever get to join them? Well, one day she met a group of Swiss Mountain Wizards called Biosensors Europe SA: they devised a special stent with a biodegradable coating and put little biolimus right inside it. Then they tested their new stent on people who had heart attacks in places around Europe and Israel. And do you know, exactly the same number of people died if they had the new stents as they did if they had bare metal stents, but the ones who had biolimus stents had fewer blockages later on. So now little Bi Olimus has bought her plane ticket and has high hopes of joining the other Olimusses in the Land of the Free, to make her fortune in the Great Stent Market.

788   Novel risk markers to improve cardiovascular event prediction in intermediate risk individuals! Don’t all leave the room this time either! I will try to make this interesting. Actually, on second thoughts I won’t attempt the impossible: just look at the ROC curves. If you add coronary artery calcium, ankle-brachial index, high-sensitivity CRP, and family history to the Framingham Risk score you increase the area under the curve. It still isn’t that great, but out of this lot, coronary calcium adds the most. Maybe you find this useful.

796    And then of course there is common carotid intima-media thickness. No, please please stay in the room! I shall be very brief. Once we were all persuaded that CIMT was the bee’s knees in risk prediction. Now we are all dumping it because, as this meta-analysis shows, “The addition of common CIMT measurements to the Framingham Risk Score was associated with small improvement in 10-year risk prediction of first-time myocardial infarction or stroke, but this improvement is unlikely to be of clinical importance.” Someone needs to remind me how we got fooled by this surrogate in the first place; it was all so long ago.

NEJM  23 Aug 2012  Vol 367
695   Bariatric surgery on a mass scale: is this really the answer to the epidemic of type 2 diabetes? Nobody feels very comfortable with the idea, but the answer from all the evidence is a resounding yes, until we come up with something better. The Swedish Study of Obese Subjects (SOS) started recruiting men with a BMI over 34 and women with a BMI over 38 in 1987, when weight reduction surgery was invasive and hazardous, and went on recruiting without randomization until 2001. Surgical practices changed, and this is not an ideal clean cohort: but the results are striking enough to make statistical niceties irrelevant: at 15 years, the adjusted hazard ratio for developing diabetes was 0.17 in the surgical group. Any form of bariatric procedure has the capacity to prevent four out of five cases of type 2 diabetes in obese people, and those most likely to benefit are readily identifiable by impaired fasting glucose.

705   Thyroid nodules have been a source of diagnostic frustration ever since people first started removing them. Up to a third of them have indeterminate histopathology and therefore have to be removed for safety. A new test which looks at 167 relevant genes in tissue samples has been produced by Veracyte, who paid for this validation study. It certainly helps to detect overt cancer and definite non-cancer, but there still is a grey area, and this paper is careful not to overstate its reliability, no doubt to avoid the inevitable litigation which would result from missed invasive cancers.

716    Eltrombopag is the Eddie Stobart or Norbert Dentressangle of the pharmaceutical motorway. I can’t resist a whoop whenever I see the name:  Eltrombopag! Eltrombopag! O keep it in your doctor’s bag!  Not that anyone really does: it’s an oral thrombopoietin-receptor agonist which is good at raising platelet counts but has a rather limited repertoire of clinical usefulness. In this trial it was used to get platelet counts above 50,000 in people with chronic liver disease who needed to have elective surgery. In the great majority, the count rose sufficiently to avoid platelet transfusion, though there were some cases of portal vein thrombosis, which led to termination of the study.

Lancet  25 Aug 2012  Vol 380
731    Here’s a trial aimed at solving the question of whether to give intravenous aspirin together with alteplase in acute ischaemic stroke. The answer is a clear no: neurological outcomes are not improved and there is a greater risk of symptomatic intracranial bleeding.

738   Psoriasis is a big potential market for new drugs, and recent years have seen the introduction etanercept and efalizumab to modify inflammatory pathways in mild-moderate disease. Celgene Corporation are taking a slightly different route with their new oral drug apremilast, which is a phosphodiesterase 4 inhibitor. As such, it’s a next-door neighbour to Viagra, but this phase 2b trial makes no mention of the fact, simply noting a small increase in headache and diarrhoea at the doses which are effective for psoriasis. This may be a drug to watch.

747   Are donor lungs from smokers as good as those from non-smokers? Well, no, of course not, but at least they are donor lungs, and if you need a pair, then it’s best not to wait around but take whatever comes your way. A fine piece of commonsensical analysis from the UK transplant database.

BMJ   25 Aug 2012  Vol 345
The Victorian novel could hardly have existed if there was no connection between psychological distress and mortality. There was even a special mode of death reserved for the more extreme kinds, known as brain fever (this was before the clinical thermometer came into wide use). But this is, alas, no mere Dickensian convenience: data from the Health Survey for England show that the association remains strongly present in the 21st century and applies at every level of distress to every common mode of dying.

Iatrogenic Cushing’s syndrome is certainly not rare, but it is quite difficult to study. These investigators used The Health Improvement Network (THIN) which as its name does not imply is simply a database of UK general practice records, kept purely for clinical purposes. By fairly laborious analysis, this study shows that having a record of being prescribed long term corticosteroids and looking Cushingoid comes with a fourfold increase in cardiovascular risk, after multiple adjustments.

Ann Intern Med  21 Aug 2012  Vol 157
233    Ever heard of saturnine gout? It’s the name given to gout caused by lead poisoning of the renal tubules. It was extremely common among the upper classes of ancient Rome, where it was generally attributed to sex and booze: “gout is the daughter of Bacchus and Venus,” Galen is supposed to have said. There is a very readable account of this in a 1983 paper from the New England Journal: it seems that late-Empire Romans mostly existed in a state of combined alcohol and lead intoxication. They drank between 1 and 5 litres of wine on ordinary days, and more at feasts; and to preserve and sweeten their wine, they used wine-must boiled down in lead containers, because lead salts taste sweet and are fungicidal. Patrician Roman bones dug up in far-flung corners of the Empire, like Cirencester in Gloucestershire, regularly show toxic levels of lead. But I digress: what has this to do with gout in modern America, a place where eyebrows are raised if you so much as pour yourself a second glass? A study from NHaNES 2005-8 looks at self-reported gout and hyperuricaemia in relation to blood lead levels well below the recognized toxic level, and finds a definite association. The renal tubules seem very sensitive to lead, even in those who generally shun the worship of Bacchus and take care with Venus.

242    Screening for lung cancer using chest CT in high-risk individuals has been shown to save lives: but before countries start embarking on costly, high-radiation screening programmes, we need to refine our definition of “high risk individuals.” In this paper a European team carries out a decision utility analysis of the Liverpool Lung Project Risk Model using data from three independent screening studies. The fit looks pretty good.

251    If you’re particularly interested in lipid-lowering therapy in people with “chronic kidney disease” then the next two papers may be for you. Decrements in eGFR tend to cause increments in cardiovascular risk, though this is mostly mediated by other factors, such as LDL-cholesterol. I can’t make much sense of the eGFR cut-off of 60, but I’m quite happy to believe the message of this meta-analysis that overall, statins lower cardiovascular risk in this population while having no effect on the progression of kidney disease.

263   The next meta-analysis (of 80 studies) puts a slightly different twist on the issue: “Statins decrease mortality and cardiovascular events in persons with early stages of CKD, have little or no effect in persons receiving dialysis, and have uncertain effects in kidney transplant recipients.” It would be nice to know that eGFR cut-off.

Plant of the Week: Rudbeckia hirta

This kind of Black-Eyed Susan is a North American plant which is particularly popular in Germany. It is like a brass-band of the plant world: the louder and the yellower it is, the better. Leave polite pastel shades to the hollyhocks and the Japanese anemones: these flowers are there to shout and tell you that summer is not over yet.

They may be a bit too Munich beer-garden for some tastes, but we love them. There are lots of cultivars, some of which veer towards the orange and the dusky. We prefer the biggest, boldest buttercup yellows, and the best place to find these is not in an expensive garden centre that sells stone pigs, but in a run-down small-town market where you can pick them up at 3 for £2. Not that you really need three: they can form enormous clumps in a short time, and they tend to push aside their tasteful neighbours. Then they will die off unaccountably and you’ll have to find some more.