Richard Lehman’s journal review—4 February 2013

Richard LehmanJAMA Intern Med  28 Jan 2013  Vol 173
93    One of the chief glories of this journal (formerly called the Archives) lies in the articles labelled LESS IS MORE, which can range from editorials to original research papers, and this issue contains no fewer than four such. The US health economy contains massive incentives to do too much, while the tendency of the NHS is often to do too little; but it is interesting to see how even in our system, we might be better off if we did less of certain things. Rita Redberg is a very hands-on editor and contributes to three pieces in this issue: here she joins forces to comment on how much overtreatment has decreased in the USA since 1999. The answer, of course, is that it hasn’t at all.

132    One treatment that we are learning to be meaner with is blood transfusion. Several studies in different contexts over the last year have shown that a restrictive transfusion policy is often associated with better survival than a liberal transfusion policy. In this systematic review, the authors look at the literature on transfusion at the time of myocardial infarction. The trials are of variable quality but in terms of all-cause mortality, the message is that less blood is more beneficial.

142   Throughout my year in the USA, I puzzled over what they mean by “primary care” as opposed to “ambulatory care” or “family practice.” Context is all. And they are trying to develop quality standards for these, so they would do well to learn from the mistakes made with our QOF. But I expect they will have to do it all themselves by trial and error. From this article on trends in the overuse of ambulatory healthcare services in the United States I deduce that there are already quality standards in place to measure “overuse” which can mean anything from too much PSA screening in the over 74s to using the wrong antibiotics in UTIs. By such measures, US primary care is not doing too well.

NEJM  31 Jan 2013  Vol 368
407   This paper reports a trial from the Netherlands which was so successful at curing recurrent Clostridium difficile that it was stopped before even half the patients had been recruited. Normal human faeces were harvested, carefully screened for pathogens and used within six hours, mixed with normal saline and introduced into the duodenum by a nasal tube. Out of 16 patients with relapsing C diff, 13 were cured at the first try and another 2 after a second infusion. Coprotherapy may have other uses too, as the editorial explains, though I can’t help wondering why it has to be administered via the upper end of the alimentary canal. It’s all rather unfortunate for sensitive gastroenterologists and patients who will now have to steel themselves to adopt this treatment, which is both totally crap and amazingly successful, rather like the late Andrews sisters.

416   A couple of weeks ago, the New England Journal published a perspective piece cautiously praising the achievements of the Cuban health system. It is legendary for its cost-effectiveness, and also for exporting cheap healthcare to the developing world. In this study the Cubans test the effectiveness of using inactivated polio vaccine at one fifth of the normal intramuscular dose by injecting it intradermally instead. This tends to hurt and to cause local reactions, but it achieves a 90% seroconversion rate, so it might be a useful trick in resource poor settings as we inch towards the global eradication of polio.

425    It’s a terrible thought that in a world where half of the food produced is thrown away, severe acute malnutrition contributes to 1 million deaths among children annually. This trial took just a year to recruit 2767 starving children in Malawi and randomize them to receive amoxicillin, cefdinir, or placebo as well as ready-to-use therapeutic food. Without antibiotics, 15% of the children died: with cefdinir, this was reduced to 9%. Every BMW limousine exported to Malawian ministers should be packed full of cefdinir for use on starving children.

436   Localised prostate cancer is largely a diagnostic artefact: the chances that I am sitting on a focus of it are about 50%, but I am not going to let any urologist anywhere near my bottom with a horrible array of biopsy needles, nor am I going to have my PSA measured. Once you have this diagnosis, you have three choices: do nothing, have radiotherapy, or have radical prostatectomy. The Prostate Cancer Outcomes Study recruited back in 1994-5 and now reports the 15-year results from the two active treatments. By this time, the effects on erectile function, continence, and bowel urgency have evened out. The 15 year charts within this paper should make excellent shared decision making aids for men with newly diagnosed localized prostate cancer—provided always that there is a doing-nothing chart to accompany them.

446    Myths, Presumptions, and Facts about Obesity: this is a great article by a number of NIH authors, well worth ordering from your medical library since the NEJM has decided not to make it open access (fat chance). It has already been much quoted and tweeted, especially the myth about the calorie-burning effects of sex. “Given that the average bout of sexual activity lasts about 6 minutes, a man in his early-to-mid-30s might expend approximately 21 kcal during sexual intercourse. Of course, he would have spent roughly one third that amount of energy just watching television, so the incremental benefit of one bout of sexual activity with respect to energy expended is plausibly on the order of 14 kcal.” Ah well. At my age, I use about that putting my slippers on.

455    How nice to read another article about organ failure in old age. Mechanisms of Disease: Proteotoxicity and Cardiac Dysfunction—Alzheimer’s Disease of the Heart? If you trespass beyond the age of 75, your heart may well begin to fail for reasons that are little to do with ischaemia but much to do with stiffening and the general clogging up of cardiomyocytes with defunct protein. At the same time, your brain may be forming plaques and tangles. Bah. Ripe old age means ripe old proteins and time to pack up.
Come Fate with thine abhorrèd shears
And take them to my telomeres.

Lancet  2 Feb 2013  Vol 381
358   Richard Horton uses his Offline column this week to repent his signing of the absurd Guidance Document which resulted from his wooing of the Association of the British Pharmaceutical Industry and the Royal Colleges. And he urges readers to attend to the petition. One can only repeat the words of Our Lord: “I say unto you, that likewise joy shall be in heaven over one sinner that repenteth, more than over ninety and nine just persons, which need no repentance.” (Luke 15:7). Just a pity this didn’t come in time for him to reject those pharma-funded, agency-written papers last week hyping regorafenib. We shall watch his penitential progress with considerable interest.

375    In the bad old days, most humans spent their days walking from place to place and labouring physically to produce things, and their evenings talking to each other. Nowadays these activities come packaged as “exercise” and “cognitive behavioural therapy,” and there is little they cannot ameliorate. Here an Australian trial shows that depression that is not fully responsive to drugs can be helped by cognitive behavioural therapy, which is a mixture of human contact and sensible advice. It did not carry this name in 1621 when Robert Burton published The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it. In Three Maine Partitions with their several Sections, Members, and Subsections. Philosophically, Medicinally, Historically, Opened and Cut Up. When this Oxford scholar needed cheering up, he would walk down to Folly Bridge to listen to the bargemen on the River Thames swearing at each other.

394   Ten thousand American veterans with dyslipidaemia in their late fifties were observed for a mean period of 10 years in this cohort study. As expected, those who took a statin had a lower mortality over this period of 9.2% in absolute terms, or in relative terms one third. Fitness, as based on peak metabolic equivalents (MET) achieved during exercise test, demonstrated even larger mortality benefits in this highly selected male population. So although I am not a black American army recruit, I can’t altogether ignore the message that keeps coming back from every observational and interventional study: even quite modest amounts of exercise in older men can lead to big gains in survival.

400   The incidence of oesophageal cancer is rising quite rapidly, and it is worrying that we don’t know why. Additionally, adenocarcinoma is taking over from squamous cell carcinoma in several developed countries. Here’s a workmanlike, textbook-style run through the evidence about the epidemiology and treatment. No real advances.

BMJ   2 Feb 2012  Vol 346
In our local shopping precinct, useful shops selling cameras, pillowcases, DVDs, and hardware have all closed down, but a certain retailer of vitamins and antioxidants still does a roaring trade. Even among doctors, there seems to be a reluctance to acknowledge that claims that these supplements improve vascular health were debunked years ago, and that to make them in 2013 is misrepresentation, pure and simple. Here is a systematic review and meta-analysis of the randomised controlled trials: no surprises, but a decent effort by several authors from Korea, which may play a part in furthering many a career.

After the first trials using bisoprolol and carvedilol in heart failure with reduced ejection fraction appeared, great efforts were made to change stable heart failure patients over from other beta-blockers to these particular “evidence-based” agents. I believe this still goes on throughout the UK, consuming the time and effort of numerous heart failure specialist nurses. Desist, dear ladies: several observational studies and now this network meta-analysis have shown that there are probably no mortality differences whatever between different ß-blockers in systolic HF, or if there are, they may even favour atenolol. Nor is the up-titrating of doses based on firm evidence. I have seen no hard data to persuade me that heart failure patients benefit significantly from more than a smallish dose of any ACE inhibitor and a smallish dose of any ß-blocker.

I spent a while puzzling over whether to believe the conclusion of this observational study which alleges that “most normally formed singleton stillbirths are potentially avoidable. The single largest risk factor is unrecognised fetal growth restriction, and preventive strategies need to focus on improving antenatal detection.” The main predictor of stillbirth is ethnicity and the main reason that the stillbirth rate in the UK is not improving is that a greater percentage of pregnancies are occurring in mothers whose inherently higher risk of stillbirth is observable throughout the world. But that is not to say that all of it is unavoidable, and on the whole I support the conclusion that better monitoring for fetal growth retardation is likely to be useful.

How the message from mortality figures was missed at Mid Staffs is a typically excellent piece of reporting by Nigel Hawkes. You would think that it is easy in a standardized system like the NHS to spot outliers and send in the inspectors: but no such luck. Not only are there many ways to massage the figures but it is actually a considerable science to analyse hospital mortality statistics, and one that nobody has mastered to the same extent as Harlan Krumholz. His editorial is an excellent short guide to what is needed. A pencil and the back of an envelope are not sufficient, as I discovered during many Friday afternoons at his Center for Outcomes Research and Evaluation over the last year.

Plant of the Week: Sarcocca hookeriana var digyna
Midwinter spring is its own season,
Sempiternal though sodden before sundown

wrote TS Eliot, in the unhappy belief that this would pass for poetry. We have just had a brief period of midwinter spring; and although it never seemed sempiternal, it was quite nice.

The fragrant sarcoccas are among the best plants to enjoy in winter sunshine, even towards sodden sundown (or sunset, as we say in England, Mr Eliot). You don’t need to go looking for them because they come looking for you in unmistakable wafts of clover honey. They are shade tolerant and should be grown in any dry unfavourable spot in the garden.

This form—hookeriana “digyna”—has pointed olive green leaves and flower tufts which carry hints of pink. But there are other kinds with plain small shiny rounded leaves and plain creamy yellow flowers. If you choose to starve them, they remain less than a metre high: otherwise they may get a little bigger. Any garden without a scented sarcococca is missing a winter treat.