Richard Lehman’s journal review—17 June 2013

Richard LehmanJAMA  12 June 2013  Vol 309
2345   “Moral panic” is a term which dates back to the 1830s and describes “an intense feeling expressed in a population about an issue that appears to threaten the social order.” Just now the Chief Medical Officer for England is putting her weight behind a campaign of moral panic about antibiotic overuse by doctors, and if I dissent I shall be considered a threat to the social order. We are supposed to confess that as GPs we greatly overuse antibiotics, and as a result they are losing their effectiveness and we are about to return to the pre-antimicrobial era. The study reported here from the USA shows that primary care paediatricians can be persuaded to use fewer broad spectrum antibiotics for respiratory infections in favour of amoxicillin and penicillin V. The fact is that after 60+ years of “overuse,” these remain highly effective first-line treatments in primary care, and you don’t need most of the rest. We may differ on the likelihood of their usefulness in particular clinical contexts, but there is no room for moral panic. Dame Sally should save that for the use of antibiotics in animal feed.

2353   If you measure C-reactive protein, leucocytes, and fibrinogen in people, what will you find? That those who are ill have higher levels, and that everyone’s levels bob up and down all the time. In this study, these “biomarkers” were found to be raised prior to exacerbations of chronic obstructive pulmonary disease. I’d have been very surprised if it were otherwise, and this isn’t going to persuade me to do weekly blood tests on COPD patients.

2335  A trial of ventilated patients on ICU found that music selected from a  range of six CDs helped to reduce sedative use in these patients, but noise-cancelling headphones worked just as well. I can’t help thinking that’s not enough CDs to choose from. If I end up ventilated on ICU, please rummage through my CDs and find the Bach violin sonatas played by Yehudi Menuhin with Malcolm and Gauntlett. Then if I died and went to heaven, I wouldn’t be able to tell.

(NB: This recording from 1961 has never been reissued on CD by EMI but is available on the little-known French label, Forgotten Records.)

NEJM  13 June 2013  Vol 368
2255   Staphylococcus aureus remains the commonest cause of healthcare associated infection; and for a time, meticillin-resistant staph aureus (MRSA) caused widespread moral panic. Fortunately it also led to an outstanding cluster-randomized trial in ICUs within the Hospital Corporation of America. In the first group of ICUs, patients with positive nasal swabs for MRSA were isolated; in the second, swab positive patients were isolated and treated with nasal mupirocin and daily whole-body cleansing with chlorhexidine impregnated cloths; in the third group there was no testing and everybody got the nasal ointment and the chlorhexidine bathing. “In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen.” A classic study, which at one stroke has solved an important clinical question, and will save lives.

2277   But alas it’s back to panic stations again. I am having to abandon my policy of not commenting on H7N9 influenza because there is so much about it in the journals. Here is a report of the clinical findings in 111 cases from Chinese hospitals. It’s bang up to date: the cut-off is May 10th 2013. This type of influenza A can be very nasty, and 27% of these patients who came into hospital, mostly with viral pneumonia, were dead by May 10th. But until we know more about the typical presentation of this virus in the community, and about human-to-human transmission, panic should be put on hold. For now. We may be doomed. But not for another week or two.

2286   Adrenaline? In the title of a NEJM paper? Surely in America it should be epinephrine. But it doesn’t matter in the end, because this Norwegian trial shows that for the hospital treatment of acute bronchiolitis in infants, inhaled racemic adrenaline (epinephrine) is not more effective than inhaled saline. And if you prescribe the saline inhalations as necessary instead of per regular schedule, the babes leave hospital sooner.

2294   A clinical review discusses acute high altitude illnesses. I shall spend the next few days in Peru, at sea level. Here is my clinical summary of acute high altitude illnesses. 1. Do not go to high altitudes 2. If you must, get acclimatized. 3. This does not apply to commercial flights.

Lancet  15 June 2013  Vol 381
Last week it was China, this week it’s the latest antivirals for HIV and HCV. You can’t argue with the intrinsic importance of these topics but you can argue that they don’t make riveting reading for the generalist doctor. For that you have increasingly to go to the BMJ—and I’m not just writing out of brand loyalty. Once again I can’t point to anything of interest in the Lancet, except perhaps a speculative paper on how a true cure for HIV might one day emerge, and a very broad-brush look at the factors which can lead to improvement in poor-world health systems.

BMJ  15 June 2013  Vol 346
Laudable pus—thick and primrose-yellow, with hints of green and streaks of red—is the good old fashioned stuff that we all enjoy releasing from abscesses whenever we get a chance. But staphylococcal pus comes in for little lauding these days. Meticillin-resistant S aureus gets all the headlines, but all staphylococci tend to cause wound infections and are worth taking measures against pre-operatively. A systematic review here shows that nasal swabbing and the use of intranasal mupirocin are useful for preventing post-operative infections and in those with MRSA, and glycopeptide antibiotics (vancomycin, teicoplanin) can be “bundled” in too.

Stroke care improvement programmes in the UK seem to work, just as stroke centres did when they were first set up. A prospective cohort study examines the figures and looks for the contribution made by each element of improved care. Once again we get this wretched word bundle, and Bundle 4 is defined as: “patient given antiplatelet therapy where appropriate and had adequate fluid and nutrition for first 72 hours.” Why on earth bundle together adequate food and fluid with antiplatelet therapy? Anyway, this bundle makes the most difference: it is perhaps a marker for units where the nurses have enough time to make sure the patients are fed and watered.

Canadian legislation to enforce the wearing of helmets by bicycle riders has made very little difference to rates of injury. This provokes a lovely editorial from Ben Goldacre and David Spiegelhalter on the perils of population evidence versus personal benefit and political correctness. I really don’t know how Ben gets time to write editorials. In fact I don’t know how he gets time to sit down, let alone eat or sleep. But I do seem to remember he wears a cycle helmet, one specially designed to contain his hair.

The main buzz in this week’s BMJ though comes from Deb Cohen’s great piece of investigative reporting on the concealed signals of pancreatic hypertrophy and damage caused by incretin mimetics. This is the glitazone story all over again, and once again reveals the lunacy of releasing drugs for long-term use on millions of high-risk individuals without the faintest idea of their long term harms or benefits. Points made in excellent editorials by Edwin Gale and Victor Montori.

JAMA Intern Med  10 June 2013 Vol 173
956   It’s great to see Iona Heath feature in a viewpoint on waste and harm in the treatment of mild hypertension in a leading US journal. It is taking so long for the entrenched models of thinking about cardiovascular risk factors to give way to a patient centred view of risk and benefit.

972   If only everything in medicine wasn’t such a mess! But we should take comfort that no generation before on earth has witnessed the advances in treatment that we have: the toll of premature death from cardiovascular disease and from cancer is coming down all the time. The trouble is that it could come down so much faster if there wasn’t such a welter of poorly conducted research and profiteering, as this study of the characteristics of oncology research reveals.

981   And the price of all this prolongation of life is that more people get old. I like Andrew Dilnot’s view that this is something we should rejoice about, but health systems just see it as a resource problem. Everybody is in the business of devising care pathways which will keep the elderly out of hospital, myself included. By which I mean I am trying to devise one before I need one. But I wonder if it is really possible to generalise across health systems. Here is panacea no 1, as trialled from a tertiary centre in Birmingham, Alabama: it is—wait for it—an interdisciplinary team which goes out into the community! Gosh, we have these in Birmingham England too!

990   And here is panacea no 2. It is called MACE and it is—wait for it—a multidisciplinary team which goes out into the community from Mount Sinai Hospital in New York! Gosh, I don’t know if we have these in New York England too. This is a little village in the bogs of Lincolnshire, which might have to rely on the good offices of the GP, district nurse, and a few kind neighbours.

Plant of the Week: Geum chiloense

This is the nearest thing to a Peruvian plant flowering in our garden at present—the alstroemerias (Peruvian lilies) come later. It’s strange to have reached the middle of June and still be waiting for an abundance of other flowers. Meanwhile, some of our geums have been in sporadic flower since March, and are covered now; better still, they will carry on into autumn. These imperturbable plants really do merit a place in every garden, filling spaces at the edge of each border.

The characteristic colours of geums are yellow, orange, and red in all shades, and there are numerous good varieties. The flowers usually nod charmingly but there are many upright ones too. Just go along to the nursery and choose. Better still, go to a friend’s garden and ask for any you like: they divide easily at any time of the year, and indeed should be divided and replanted every third year or so, to keep at their best.