Richard Lehman’s journal review—22 April 2013

Richard LehmanJAMA  17 Apr 2013  Vol 309
1607   Why do some babies get colic every evening until they are about three months old? Dunno. Why do some children and adolescents get migraine? Dunno. Connect the two dunnos and you get a third—why are children and adolescents who get migraine six times more likely to have a history of infantile colic? That’s the discovery of an Italian study based on children aged 6 to 18 attending emergency departments for migraine: just a reminder of how little we understand about either condition.

1613   As the saying goes, death is Nature’s way of telling you to slow down. Short of death, coronary heart disease and stroke could be thought of as timely reminders to get fit. But people who have CHD or stroke seem remarkably resistant to heed Nature’s warning: in rich countries and poorer countries alike, they continue to have sedentary lifestyles, and few alter their diet. But at least 50% of them give up smoking.

NEJM  18 Apr 2013  Vol 368
1477   Seriously ill people often have high levels of blood cortisol. A Belgian study of patients on intensive care units tries to sort out why this should be. In most cases it is not due to activation of the hypothalamic–pituitary–adrenal axis: on the contrary, corticotropin levels are usually low. “During critical illness, reduced cortisol breakdown, related to suppressed expression and activity of cortisol-metabolizing enzymes, contributed to hypercortisolemia and hence corticotropin suppression. The diagnostic and therapeutic implications for critically ill patients are unknown.” A nice piece of basic clinical science.

1489   Staying in the ICU, an international randomised trial assesses the effect of giving antioxidants and glutamine to critically ill people. Anti-oxidants do not improve outcomes, and glutamine increases in-hospital mortality. Or, as Natural News (May 2012) puts it: “The healing powers of glutamine are vast and understated. This completely safe and natural amino acid supplement has been studied for the past 15 years for its unique and compelling healing properties.”

1498   Many hospitals in the USA offer percutaneous coronary intervention although they lack on-site cardiac surgery facilities should things go wrong. This study of Massachusetts hospitals shows that non-emergency PCI has now become such a safe procedure that it there is no difference in outcomes between hospitals with or without on-site surgical rescue.

1528   So far, I’m distinctly struggling to find anything of generalist interest in the journals this week. How about belimumab for systemic lupus erythematosus? Come on, let’s give it a go: you may never use the stuff, but the chances are that you come across SLE now and again. It is a horrible disease for the great majority of patients who suffer frequent flare-ups and within 6 years usually show organ damage due to the disease or steroid treatment. So if there really was a safe disease-modifying treatment for SLE, it would be a major advance. But this review does not inspire confidence in this antibody to B-lymphocyte stimulator: there seems to be a rule of thirds at work—one third get better, one third stay the same and one third get worse. And they all risk a lot of adverse effects and massive expense, with belimumab infusions costing $2,000 a time.

Lancet  21 Apr 2013  Vol 381
1346   Richard Horton’s Offline column seems determined to fly off into realms beyond parody: two weeks ago, his wisdom came from Bali; last week from Stockholm; and this week our dear leader is in Singapore, declaring that “None of us, let alone our governments, knows when or how much healthcare we will need. But we will need it. We will expect it. We will demand it.” As his car moves slowly along the waterfront towards the airport which will take him to his next conference, everyone salutes. Many are moved to tears.

1361   Meanwhile, back in the Lancet offices, the remaining staff realise that they need something to print in their journal. People will expect it. They will demand it. How about an experimental trial of brain electrodes for anorexia nervosa? This one pushes all the right Frankenstein buttons to ensure lay press coverage: and it also suggests that deep brain stimulation could turn out to be a viable treatment for refractory anorexia in consenting patients, once it has had a proper trial. This phase one study from Toronto recruited six patients and found that they mostly felt better with the intervention, and three gained weight. There was a seizure; an air embolism; a panic attack during surgery, but overall “subcallosal cingulate DBS seems to be generally safe in this sample of patients with chronic and treatment-refractory anorexia nervosa.”

1371   The much-awaited arrival of DSM-5 (the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) should ensure that every human being is classed as insane. At this point we might be able to start again and consider what psychiatry is for. Genomics is keen to help in the effort by finding the loci that are associated with all sorts of mental disorders. Enter a huge population based study funded by the National Institute of Mental Health: “Our findings show that specific SNPs are associated with a range of psychiatric disorders of childhood onset or adult onset. In particular, variation in calcium-channel activity genes seems to have pleiotropic effects on psychopathology. These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.” Hmm. I think that when authors have to use words like “pleiotropic” and “nosology” there is a high chance that they do not know what they are talking about. So before welcoming the marriage of genomics and psychiatry, let us remember that there is a strong history of madness on both sides.

BMJ  21 Apr 2013  Vol 346
Here’s a systematic review of coronary calcium scoring in type 2 diabetes. The BMJ likes to publish systematic reviews, which are supposed to tell us what to believe from close study and aggregation of the best randomized trials. To read what I think about that, you’ll need to look at a piece of mine called Nullius in Verba which is out in the forthcoming issue of JAMA Internal Medicine. Systematic reviews need taking with a pinch of salt, as last week’s BMJ offerings proved. But back to coronary calcium scoring in diabetes: why do it in the first place? The obvious answer is to select high risk patients for more intensive treatment—the excuse always given for doing all sorts of futile prognostic testing. Coronary calcium scoring is useless for this—it has high sensitivity, but low specificity. Right then, don’t despair—let’s use it for identifying low risk patients for less intensive treatment. In theory, you could do this—but in practice, would you really want to subject all your diabetic patients to an expensive, high radiation procedure which would cause unnecessary anxiety in 20 for every lucky one who could then be offered one (statin) tablet less a day?

Desperate for something to write about this week, let me tell you about a Canadian trial which offered first time mothers-to-be a behavioural-educational sleep intervention which included a 45-60 minute meeting with a nurse to discuss sleep information and strategies to promote maternal and infant sleep, a 20 page booklet with the content discussed, and phone contacts at one, two, and four weeks postpartum to reinforce information, provide support, and problem solve. This failed to have any effect on the mothers or the babies, though I must say that reading about it last thing at night definitely showed signs of working for me.

Leave well alone! This is a lesson that doctors are bad at learning. Midwives need to learn it too: it may suit us all to try and speed up the third stage of labour, but a randomised trial in five French hospitals shows that pulling on the cord does not help to reduce postpartum bleeding. Just have a cup of tea and let the placenta emerge au naturel. I shall not discuss its culinary merits, but point you to the 771,000 entries which you can find by putting “placenta recipe” into Google.

The cover of the BMJ asks what we really know about what makes us fat, and Gary Taubes offers an essay which suggests that the answer is not much. If you want lessons to take from this week’s BMJ it’s best to turn to the Education section and read about investigating suspected scaphoid fractures (hint—do an MRI), delirium in the elderly (hint—take a proper history, think infection and medication); or learn about pulmonary hypertension from a good review, in case you come across an unfortunate patient with the condition.

Ann Intern Med  16 Apr 2013  Vol 158
573   Those of us who work in the academic field of shared decision making are painfully aware of the lack of clinician buy-in and the need to understand its causes. What we need are ethnographic studies of actual consultations to understand better what actually happens when clinicians do or don’t share the process of decision-making. So I should welcome this study of what happens in real life in 2 Veteran’s internal medicine clinics, but I’m not sure I would count it as ethical: “patients surreptitiously audio-recorded encounters with their physicians”—meaning that the subjects of the study do not seem to have given consent. Still, I would really like to hear these audio tapes—if only I had time enough, and I could get retrospective consent from the physicians. The rather mechanistic analysis they get here doesn’t really get us beyond the fact that when doctors listen to patients, outcomes usually improve.

Plants of the Week: Narcissus pseudonarcissus with Anemone nemorosa

In our part of England the hedgerows are still mostly brown, and spring is still partly on hold, but on a whim we drove down to the Welsh border area west of Gloucester to see if we could cheer ourselves up in the daffodil woods near Dymock. There are no woods like these anywhere else on earth, as far as I know—woods where wild daffodils grow as far as the eye can see, broken only by drifts of beautiful white wood anemones.

Usually the daffodils are going over before the anemones are in full flower, but this year they reached perfection together. The sun came out, a scent of daffodils filled the air, and we wandered dreamily through the enchanted woodland, blissed out and incredulous.

And soon, in other English woods, there will be bluebells, and more bluebells. While ever there are snowdrops, and daffodils, and wood anemones, and bluebells, the winters of England will be worth enduring in hope.