Richard Lehman’s journal review—4 November 2013

Richard LehmanJAMA Intern Med  28 Oct 2013  Vol 173
1770    There is very little in the journals this week: JAMA is taking a week off and even JAMA Intern Med has thin pickings. Two trials tell us what we expected. It’s a very obvious fact that poorly educated black women in the USA are often obese. This trial enrolled 194 overweight and slightly obese (mean BMI 30.2) such premenopausal women and examined the effect of “tailored behavior change goals, weekly self-monitoring via interactive voice response, monthly counselling calls, tailored skills training materials, and a gym membership.” This intervention was slightly beneficial: 62% weighed the same or less after a year versus 45% in the “usual care” group. Note that this was a trial in low-income black women on the brink of obesity: it does not try to address the problem of the vast number who are already well past the threshold.

1780   A study of outcomes following falls demonstrates that recovery depends in large part on the state of health preceding the fall. As we all know. “Rapid recovery was observed only among persons who had no disability or mild disability, and a substantive recovery, defined as rapid or gradual, was highly unlikely among those who had progressive or severe disability. The postfall trajectories were consistently worse for hip fractures than for the other serious injuries.”

1788   Most papillary thyroid “cancers” don’t behave as cancers at all. And an awful lot of people have small thyroid nodules that yield suspicious histology if you do needle biopsies. There is clearly an overdiagnosis problem, because the number of “cancers” diagnosed has quadrupled over the last 30 years, as has the number of thyroidectomies, but mortality from thyroid cancer has not changed. Rita Redberg, the journal’s editor, describes how she herself found herself having to make difficult decisions as the result of having this diagnosis. Clearly we need better diagnostic pathways, and the study here shows that if two criteria for biopsy are used rather than putting a needle into all nodules bigger than 5mm, you can cut the biopsy rate by 90% while maintaining a low risk for cancer.

1808    Survivors of myocardial infarction in the Nurses’ Health Study (women) and the Health Professionals Follow-up Study provided food diaries which allowed the authors of this study to assess how “healthily” they ate and what effect this had on their survival. The score they used (AHEI2010) was based on an idealised “Mediterranean diet” and includes bonus points for moderate alcohol intake. Those who followed this diet had lower all-cause mortality after MI. Mildly interesting, but like all observational dietary studies, not actually science.

NEJM  31 Oct 2013  Vol 369
It’s uncommon to have to write off a whole issue of the New England Journal of Medicine, but I really couldn’t find anything of general interest this week. There are a couple of oncology papers reporting interventions of dubious benefit. The first is about using autologous stem-cell transplantation early in aggressive non-Hodgkin’s lymphoma. If that’s something you’re likely to be doing in the near future, then please read this paper carefully.

Otherwise, move straight on and join me in skipping past a nasty new treatment for pancreatic cancer which improves survival by 1.8 months at the cost of a lot of myelosuppression and neuropathy (and heaven knows how many thousands of dollars).

If you carry on flipping the pages of the NEJM, you can find a description of eight unrelated families from North Africa with a tendency to deep fungal skin infections, which can prove fatal: this is due to CARD9 (caspase recruitment domain–containing protein 9) deficiency, now traceable to a genetic locus with autosomal recessive inheritance and complete penetrance.

If you are an HIV doctor or public health physician, you will want to read a special report which shows that early initiation of antiretroviral therapy is more cost-effective than late initiation of ART in preventing disease transmission among HIV-serodiscordant couples in South Africa and India.

And if you are the kind of doctor who sees a lot of circulatory shock, you may want to read the latest clinical review on this topic.

Lancet  2 Nov 2013  Vol 382
1485   The current issue of New Scientist contains an Instant Expert supplement called “Our Inner Tails,” from which I learned to my great surprise that almost every cell in the human body (except hepatocytes) has a little tail, an immobile ciliary remnant which acts as a cellular sensor. These primary cilia usually contain two proteins that form calcium channels, polycystin 1 and 2, but these are missing or misplaced in people with polycystic kidney disease. It seems that kidney cells use their non-beating little tails to sense fluid flow, and if they can’t do that properly, cysts start to form and keep growing. I thought I’d pass this on to you because the actual Lancet paper on polycystic kidney disease is quite boring. It describes an inconclusive Italian trial which uses the somatostatin analogue octreotide in long-acting release form to suppress cyst progression by acting on cyclic AMP. Unfortunately this probably gives people gallstones in the long term, but the triallists claim that their data justify starting a big phase 3 trial of long-acting octreotide.

1496   Ooh, and here’s another paper about something you don’t need to know but might find faintly interesting. Paediatric urologists now sometimes invade the womb to place vesico-amniotic shunts if ultrasound shows a blocked urinary tract in the fetus. This condition is called LUTO – fetal lower urinary tract obstruction—so with a horrible inevitability the trial described here is PLUTO. The conclusion of the abstract is bafflingly worded: “Survival seemed to be higher in the fetuses receiving vesicoamniotic shunting, but the size and direction of the effect remained uncertain, such that benefit could not be conclusively proven. Our results suggest that the chance of newborn babies surviving with normal renal function is very low irrespective of whether or not vesicoamniotic shunting is done.” Basically the trial couldn’t recruit sufficient subjects: most of the babies died, and the main cause of death was pulmonary hypoplasia. So we aren’t any further forward.

1507   Danes who reach the tenth decade of life are doing so in better shape than they used to. The study compared results from two cohort studies which measured similar things, one conducted in 1998 and the second in 2010. “Despite being two years older at assessment, the 1915 cohort scored significantly better than the 1905 cohort on both the cognitive tests and the activities of daily living score, which suggests that more people are living to older ages with better overall functioning.”

BMJ  2 Nov 2013  Vol 347
Bariatric surgery is the only intervention for obesity which really makes a difference. This meta-analysis proves the point, but remains guarded: “Compared with non-surgical treatment of obesity, bariatric surgery leads to greater body weight loss and higher remission rates of type 2 diabetes and metabolic syndrome. However, results are limited to two years of follow-up and based on a small number of studies and individuals.” I guess we will never really feel happy about this type of surgery. There has to be a better way, that doesn’t involve messing with the digestive tract. Perhaps it will come when we know how to tinker effectively with the hormones that drive us to eat too much.

Here is a double-blinded trial from Barcelona that randomized 416 people with uncomplicated acute bronchitis to receive co-amoxiclav, ibuprofen or placebo, and measured the duration of their symptoms. Serious bacterial disease was excluded by clinical examination and rapid CRP testing. The coughing Catalans improved at the same rate whichever treatment they received. This is a really neat study. Homage to Catalonia!

Hospitals as we know them began to appear three hundred years ago. Thoughtful physicians were excited by the idea that you could put sick people together in one building and actually find out what happened to them. In 1731, when there was only one modern hospital in England, Francis Clifton published a tract called Tabular observations recommended as the plainest and surest way of practising and improving physick. Since then, I don’t think there has been any conceptual progress in the field. Everything depends on the kind of honest and complete recording of patient outcomes that Clifton advocated, and this still doesn’t happen. Take death. Nice and simple: even Schrödinger’s cat was either dead or alive once you observed it. But hospital patients, it seems, can remain in a state of quantum superposition even after they have died. A study of 60 Dutch hospitals finds that by applying different mortality timeframes, you can produce a big difference in standardised mortality ratios and differences in performance assessments of individual hospitals. In other words, hospitals are still playing the game of discharging dying patients to expire elsewhere, just as they did in the eighteenth century, and the nineteenth, and the twentieth. Clifton, whose prose reveals a sparkling sense of humour, must be chuckling darkly in his Jamaican grave.

A Brill Meal

One day you may find yourself in possession of a fine specimen of fresh brill, weighing upwards of a kilo or so. The brill is a handsome flatfish closely resembling a turbot, but while a turbot has thick skin and firm flesh which keeps well for about three days, the brill is thin-skinned and its flesh quickly softens and deteriorates once it has been 24 hours out of the sea.

The chance to eat perfect brill will not come often. The fish needs to be bought straight from the boat, or from a boatman who comes overnight with his freshest catch to sell it to you in your landlocked corner. We have such a boatman and his twice-monthly visits shape our very lives. They cannot be missed. Even his whelks are strangely edible.

We brought home our brill, firm and fragrant, and summoned friends to help us eat it, but they could not come. But if we waited a day, the fish might be fit only for stock or soup. So it was necessary to devise a meal of nothing but large quantities of brill for two.

Placing the fish with its down side down, proceed to divide the white side into two fillets. Take these and with the skin side down remove the flesh from the skin with a very sharp knife angled downwards. Chop the flesh into 1.5cm squares and make a ceviche as I described for turbot three months ago. As brill is soft-fleshed, the ceviche should be eaten within 4-6 hours. You will remember that the other ingredients are chopped red onion, a small amount of finely chopped red chili, lovage (important), coriander, rock salt, and a marinade of the juice of three limes and a lemon. Some persons add the flesh of a seeded tomato, but we are not of their persuasion.

Turning to the remaining brill, cut similar fillets from the dark side, which will be considerably thicker. When the ceviche has had its time in the refrigerator, start making a beautiful béarnaise sauce using three or four of the finest eggs you know of (Cotswold Legbars are our favourite) and 5 ounces of the best unsalted butter. Watch over this sacred unguent carefully, for as long as your long-honed skill requires. The less skilled participant can be opening a bottle of pungent New Zealand sauvignon to accompany the ceviche as he puts it on chilled plates, and a lovely white Burgundy for the cooked fish—a 1995 Meursault if you have it, or a Chassagne Montrachet Premier Cru of more recent vintage, perhaps.

Once the béarnaise is ready, it can be set aside in a warm place, and the ceviche can now be devoured. Immediately after, a frying pan needs to be charged with butter and put on a fierce flame to receive the remaining fillets of brill, skin side down. Spinach should be put to wilt in a nearby pan. After a minute or two to crisp the skin, the brill can be cooked at lower heat for about three minutes on each side. It is then served with its skin on top, covered in béarnaise with an accompanying little mound of spinach.

This should be eaten slowly and joyfully, perhaps to the accompaniment of a Mozart quintet. You can travel the world in search of finer food, but you will not find it.