Richard Lehman’s journal review—21 January 2013

Richard LehmanJAMA Intern Med  14 Jan 2013  Vol 173
The Archives of Internal Medicine have now morphed into JAMA Internal Medicine. It would be nice to report that this first issue is a cracker, but unfortunately journals can only be as good as the material that comes in, and the JAMA truck seems to have been pretty empty this week. JAMA Internal Med has thin pickings, and the “parent” journal JAMA has nothing to interest this UK generalist.

46   In the US medical literature, it seems to be thought scientifically and politically correct to use the label “black” to mean anyone of African ancestry. But we must remember that the West Africans who were caught and survived the slave-boat journey to America are not likely to be typical of all Africans or “blacks,” who have the largest genetic diversity on the planet. Still, let’s put aside these reservations and look at some North American “black” epidemiology relating to stroke and hypertension. In this population, “blackness” confers a much higher risk of stroke for every increment of systolic blood pressure above normal. And because BP tends to be less well controlled in American black hypertensives than in whites, incident stroke before the age of 65 is 2-3 times commoner.

NEJM  17 Jan 2013  Vol 368
201   The Patient Experience and Health Outcomes is a topic which deserves a book, but while I am trying to write it, you can take a look at this short Perspective which restricts itself to the question “Do patients’ reports of their healthcare experiences reflect the quality of care?” By patients’ reports, the authors seem to mean the kind of questionnaires that have long been used in research and are now increasingly used by providers to measure “satisfaction.” But the question as put is too poorly defined to allow an answer, so the discussion meanders back and forth. The fact is that it is possible for patients to be satisfied with truly dreadful care—for example an unnecessary diagnostic procedure detecting an incidental tumour leading to an operation with life-threatening complications followed by immense gratitude from the patient who thinks their life has been saved. That said, most examples of patient dissatisfaction are markers of poor care in some way; because although there are some outrageously unreasonable patients, I think they are far outnumbered by patients who receive an outrageously unreasonable standard of care.

207   The SPARTAC trial set out to discover if giving short-course antiretroviral treatment to patients soon after the discovery of HIV infection had any advantage over treatment when their CD+ count had fallen to a prespecified level. I am simplifying: the trial actually recruited using a wider definition of “primary HIV” but you will have to seek details from the full paper (free) using the link. It wasn’t a big hit: “We found that a 48-week course of ART during primary HIV infection delayed a decline in the CD4+ count to less than 350 cells per cubic millimetre or the initiation of long-term ART, but this delay was not significantly longer than the 48-week treatment period.” However, there were some promising subgroups and hints of long-term benefit, so the work goes on.

254   It’s time to stop watching the snow falling by the lamp-posts, close the curtains, poke the fire and get out some old DVDs. Now what have we here? The Star Wars trilogy, Lord of the Rings, Agatha Christie’s Poirot: the Complete Collection—and oh look, Drug Eluting Stents from NEJM studios. Starring Giulio Stefanini as Sirolimus and David Holmes as Paclitaxel. How about it, folks? Nah—let’s have Game of Thrones. We prefer bare metal.

Lancet  19 Jan 2013  Vol 381
205   Helicobacter pylori has lived in mammalian stomachs for tens of millions of years, but we humans have spent the last 20 years trying to eradicate it. Its pattern of antibiotic susceptibility varies across the world, reflecting the various agents that have been used to attack it. In recent years, we have a lot of information from the Italian battlefield, but here we get a report from Taiwan. These researchers decided to compare triple therapy with lansoprazole, amoxicillin, and clarithromycin for 14 days with a 10 or 14 day sequential regime which included these drugs plus metronidazole. You could go on tweaking these regimes for ever, of course, but there was a small difference in favour of the 14-day sequential regime in the Taiwanese population.

242   Many Lancet seminars get bogged down in endless genomic detail and speculation, but because most hypertrophic cardiomyopathy has now been shown to be due to mutations of just 11 genes, the authors can concentrate on clinical issues, which they do very well. “After more than 50 years, hypertrophic cardiomyopathy has been transformed from a rare and largely untreatable disorder to a common genetic disease with management strategies that permit realistic aspirations for restored quality of life and advanced longevity.”

BMJ   19 Jan 2013  Vol 346
We naturally tend to associate sweetness with pleasure, and the excessive use of sugar was therefore always likely to attract the wrath of puritans. Jim Mann here looks at the whole literature on sugar consumption in relation to body weight in adults and children. Alas, yes, too many sweeties will make you fat.

Personally I don’t like sweet things much, so I have to resort to fat to get fat. This is also successful. And if you want to lose fat, eating less fat can help—though not much. “Lower total fat intake leads to small but statistically significant and clinically meaningful, sustained reductions in body weight in adults in studies with baseline fat intakes of 28-43% of energy intake and durations from six months to over eight years.” I am off to eat some roast duck. Who knows where I shall be in 8 years’ time.

I do wish the debate about cancer screening was less polarized. I blame the screeners, because they have been so shameless in overstating the benefits; but I don’t want my own zealous scepticism to get in the way either. This study tries to assess the time-lag to benefit from screening for breast and colorectal cancer, but because the data may be skewed and the sums are difficult, I’m not sure whether to trust the conclusion, and the rather naïve editorial by Julietta Patnick is no help. She states that cancer-specific mortality is the end point most people agree on. I don’t: I want to know about all-cause mortality. Some very carefully constructed and meticulously objective decision aids are needed for everyone who enters these screening programmes.

The Winter Garden
The laurels with the winter strive;
The crocus burnishes alive
Upon the snow-clad earth;
For Adoration myrtles stay
To keep the garden from dismay,
And bless the sight from dearth.

The pheasant shows his pompous neck;
And ermine, jealous of a speck,
With fear eludes offence:
The sable, with his glossy pride,
For Adoration is described,
Where frosts the waves condense.

The cheerful holly, pensive yew,
And holy thorn, their trim renew;
The squirrel hoards his nuts;
All creatures batten o’er their stores,
And careful nature all her doors
For Adoration shuts.

Why Adoration? It is because this is an extract from an ecstatic poem addressed to King David in his role as author of the Psalms by Christopher Smart (1722-1771). He may or may not have been in an insane asylum when he wrote A Song for David—accounts differ—but he probably did not mind, provided he could read the psalms and had his cat with him:

For I will consider my Cat Jeoffry.
For he is the servant of the Living God, duly and daily serving him.
For at the first glance of the glory of God in the East he worships in his way.
For is this done by wreathing his body seven times round with elegant quickness.
For then he leaps up to catch the musk, which is the blessing of God upon
**his prayer.
For he rolls upon prank to work it in.
For having done duty and received blessing he begins to consider himself.
For this he performs in ten degrees.
For first he looks upon his forepaws to see if they are clean.
For secondly he kicks up behind to clear away there.
For thirdly he works it upon stretch with the forepaws extended.
For fourthly he sharpens his paws by wood.
For fifthly he washes himself.
For sixthly he rolls upon wash.
For seventhly he fleas himself, that he may not be interrupted upon the beat.
For eighthly he rubs himself against a post.
For ninthly he looks up for his instructions.
For tenthly he goes in quest of food.
For having considered God and himself he will consider his neighbor.
For if he meets another cat he will kiss her in kindness.
For when he takes his prey he plays with it to give it a chance.
For one mouse in seven escapes by his dallying.
For when his day’s work is done his business more properly begins.
For he keeps the Lord’s watch in the night against the adversary.
For he counteracts the powers of darkness by his electrical skin and glaring eyes.
For he counteracts the Devil, who is death, by brisking about the life.
For in his morning orisons he loves the sun and the sun loves him.
For he is of the tribe of Tiger.
For the Cherub Cat is a term of the Angel Tiger.
For he has the subtlety and hissing of a serpent, which in goodness
**he suppresses.
For he will not do destruction if he is well-fed, neither will he spit
**without provocation.
For he purrs in thankfulness when God tells him he’s a good Cat.
For he is an instrument for the children to learn benevolence upon.
For every house is incomplete without him, and a blessing is lacking in the spirit.
For the Lord commanded Moses concerning the cats at the departure of
**the Children of Israel from Egypt.
For every family had one cat at least in the bag.
For the English Cats are the best in Europe.
For he is the cleanest in the use of his forepaws of any quadruped.
For the dexterity of his defense is an instance of the love of God
**to him exceedingly.
For he is the quickest to his mark of any creature.
For he is tenacious of his point.
For he is a mixture of gravity and waggery.
For he knows that God is his Saviour.
For there is nothing sweeter than his peace when at rest.
For there is nothing brisker than his life when in motion.
For he is of the Lord’s poor, and so indeed is he called by benevolence
**perpetually—Poor Jeoffry! poor Jeoffry! the rat has bit thy throat.
For I bless the name of the Lord Jesus that Jeoffry is better.
For the divine spirit comes about his body to sustain it in complete cat.
For his tongue is exceeding pure so that it has in purity what it wants in music.
For he is docile and can learn certain things.
For he can sit up with gravity, which is patience upon approbation.
For he can fetch and carry, which is patience in employment.
For he can jump over a stick, which is patience upon proof positive.
For he can spraggle upon waggle at the word of command.
For he can jump from an eminence into his master’s bosom.
For he can catch the cork and toss it again.
For he is hated by the hypocrite and miser.
For the former is afraid of detection.
For the latter refuses the charge.
For he camels his back to bear the first notion of business.
For he is good to think on, if a man would express himself neatly.
For he made a great figure in Egypt for his signal services.
For he killed the Icneumon rat, very pernicious by land.
For his ears are so acute that they sting again.
For from this proceeds the passing quickness of his attention.
For by stroking of him I have found out electricity.
For I perceived God’s light about him both wax and fire.
For the electrical fire is the spiritual substance which God sends from heaven
**to sustain the bodies both of man and beast.
For God has blessed him in the variety of his movements.
For, though he cannot fly, he is an excellent clamberer.
For his motions upon the face of the earth are more than any other quadruped.
For he can tread to all the measures upon the music.
For he can swim for life.
For he can creep.

From Jubilate Agno, written in confinement at St Luke’s Hospital, 1759-63.
FOR I pray the Lord JESUS that cured the LUNATICK to be merciful to all my brethren and sisters in these houses.