Richard Lehman’s journal review—18 November 2013

Richard LehmanNEJM 14 Nov 2013 Vol 369
1880 As the Affordable Care Act splutters into action in the USA, JAMA devotes a whole issue to discussing the problems of healthcare in America. But for sheer gut-wrenching impact, there is nothing to beat this free-access article in the NEJM, Dead Man Walking. An uninsured man has just spent up his life’s savings for a CT scan which shows he is riddled with the bowel cancer he could not afford to have treated sooner. Obamacare is just too little, and has come too late for this poor man.

1883 “The data from our study reinforce the view that cultures of midstream urine generally are not indicated in the treatment of healthy premenopausal women with presumptive cystitis.” On their way towards reaching this conclusion, the authors went to the trouble of comparing cultures from mid stream specimens with cultures from bladder catheter samples in women with uncomplicated cystitis. They found that E coli in the MSU, even at low counts, accurately reflected E coli in the bladder. But enterococci and group B streptococci were rarely found on their own in these symptomatic women, and the authors conclude that they probably do not cause cystitis by themselves.

1892 Blockade of the renin-angiotensin-aldosterone system has been one of the therapeutic triumphs of the last 30 years. Or has it? It has certainly brought in tens of billions of dollars in profit to drug companies. For patients with systolic heart failure, ACE inhibitors, or ARBs can bring about modest improvements in survival for some patients, though we do not know how these drugs would compare with, say, the old aldosterone blocker spironolactone used in low doses as first-line treatment. ARBs and ACE inhibitors also provide extra options for the treatment of high blood pressure, but they seem less effective at preventing stroke than thiazide diuretics. And they reduce albuminuria in diabetes, but there is only weak evidence that they confer any greater protection against end-stage renal failure than other BP lowering agents. Despite three decades of hype, I suspect the world would not be much different without them. As for combining ACE inhibitors with ARBs in diabetic patients with albuminuria, don’t go there: the VA NEPHRON-D trial reported here is only one of three which has been stopped early for harm, despite reducing albumin excretion in these patients. A mournful editorial observes that ” The results suggest that improvement in surrogate markers—lower blood pressure or less albuminuria—does not translate into risk reduction. Does this invalidate the relatively new risk marker albuminuria and the classic risk factor blood pressure as therapeutic targets in our patients with type 2 diabetes?” Well, yes, actually. There are no short cuts. With every single agent, you need to find out what happens to patients.

1926 Failure to publish the results of clinical trials is a breach of medical ethics, argued Iain Chalmers over 20 years ago, and I agree. In a BMJ editorial a couple of years ago I suggested it should be a matter for disciplinary action. And this doesn’t by any means apply just to the pharmaceutical industry. In this paper, researchers from within the US National Heart, Lung, and Blood Institute (NHLBI) Division of Cardiovascular Sciences look at the publication of reports from research funded by their institution. At 30 months after data collection was complete, only 57% of the trials had been published. Fortunately this figure included most of the most heavily funded trials with patient important outcomes.

JAMA Intern Med 11 Nov 2013

1863 Medical lore has it that women with myocardial infarction are more likely than men to present without typical chest pain, and this is confirmed in this study which looked at the presentation of MI in 1015 patients aged 55 or less: 19 % of women presented without chest pain compared to 13.7% of men. “Patients without chest pain reported fewer symptoms overall and no discernable (sic) pattern of non–chest pain symptoms was found.” But then the authors suggest that “Strategies that explicitly incorporate assessment of common non–chest pain symptoms need to be evaluated.” I don’t see how that can be done if they follow no discernable (sic) pattern. But you must be patient and wait for the Yale VIRGO study, if you want to know everything that can be known about the presentation of MI in younger women.

1879 “Continuity of Care and the Risk of Preventable Hospitalization in Older Adults” is nothing if not a hot topic in the USA, as it is in the UK, but our systems are radically different. And this Dartmouth study simply demonstrates that higher Medicare costs for ambulatory care seem to be reflected in small reductions in hospital admission.

1896 The Less is More article this week provides one more piece of evidence that when patients coming into hospital with acute coronary syndrome have hyperglycaemia, you do more harm than good if you try to control their sugar within tight limits. Many previous studies (which I haven’t commented on) have shown this, and here it is demonstrated in a single-centre, prospective, open-label, randomized clinical trial in a large teaching hospital.

JAMA 13 Nov 2013 Vol 310
1921 “The ambitious nation that rallied to create the Marshall Plan, get to the moon first, and birth Medicare and Medicaid decides to move toward the healthcare it needs: universal, responsive, and affordable. But that task does not unite the nation; it rends it into political tatters.” So speaks the great Donald Berwick, and he should know. ” The litany is long of important problems in healthcare reform for which solutions have lately stalled on the shoals of angry, scientifically uninformed political combat: the proper use of evidence in clinical decision making, exploring new roles for nonphysician clinicians, enormous regional variations in care and outcome, addressing the nation’s obesity epidemic, maddeningly complex and anachronistic rules for physician and hospital payment, and much more.” I would quote the whole article if I could, mixed metaphors and all (“litany”, “stalled” “shoals” and “combat” in the same half sentence: tut). JAMA should not have put it behind a paywall.

There follow ten contributions from leading figures in US medicine, offering their personal solutions. If this is the best they can come up with, there is little hope for healthcare in America.

Lancet 16 Nov 2013 Vol 382
1629 Helping people to stop smoking is one of the most urgent tasks in public health. There are plenty of ways to do this, all with low rates of success. This New Zealand trial shows verified cessation rates of 7•3% with nicotine e-cigarettes, 5•8% with patches, and 4•1% with placebo e-cigarettes. So electronic cigarettes as an aid to cessation come in the same league as all other nicotine substitution products. But they have come under attack as possibly “renormalizing” the habit of smoking combustible tobacco. I doubt it. They may “renormalize” addiction to nicotine, but that is a price worth paying if it can prevent the death of tens of millions of people through inhaling smoke. As the editorial says, “The main untapped potential of e-cigarettes might not be in treatment of the minority of smokers seeking help with quitting, but rather as a safer consumer product for use by smokers in general. Such use could ultimately lead to the disappearance of combustible tobacco products and to the end of the epidemic of smoking-related disease and death.”

1638 Here is a paper which has got into The Lancet but would have been equally at home in JAMA Intern Med‘s excellent Less is More series. The German IABP-SHOCK II trial recruited patients with cardiogenic shock complicating acute myocardial infarction, who were undergoing early revascularisation and receiving optimum medical therapy. Half of them were randomized to receive intra-aortic balloon pump (IABP) circulatory support. This gave cardiologists something to do while these very sick patients either died or survived, but it did not make any difference to 30-day mortality. This study confirms that there was no all-cause mortality benefit at 12 months either.

1656 Do you find food allergy in children a tiresome and confusing subject? Join the club. But it is one that doctors who look after children can’t avoid, as it affects roughly 4% of kids in developed countries. This Lancet review is an excellent update on the topic, sadly hidden behind a paywall from most of those who need to read it. This is particularly unfortunate for British GPs, who seldom have timely access to allergy clinics for children. I suppose that most CCGs will restrict access to IgE testing as well. Such are the joys of an economic upturn, accompanied by permanent austerity and a collapsing NHS. Anyway, if you are interested in preventing IgE mediated food allergy in atopic families, encourage the early introduction of cow’s milk, eggs and nuts. That’s “current thinking”, though I ‘m not convinced it’s any more scientifically based than traditional thinking, which said the opposite. If I were you, I’d just lie low and agree with whatever the health visitor said. Or if the parents get to see a paediatrician, agree wholeheartedly with her views instead.

BMJ 16 Nov 2013 Vol 347

“We performed network meta-analysis using the bayesian hierarchical random effects model proposed by Lu and Ades. The advantages of using a bayesian meta-analytical approach are that direct probability statements on treatment comparisons can be made, and that all evidence for a specific problem can be taken into account as it includes evidence on both indirect and direct comparisons, and as such allows estimation of the comparisons between interventions that have not been examined directly in previous trials.” On this basis—which I am sure you all understand—the authors of the meta-analysis conclude ” Our analyses show the renoprotective effects and superiority of using ACE inhibitors in patients with diabetes…” Pardon me, but when I look at the Bayesian hierarchical effects analysis from the trials presented as a Forest plot in figure 4 I can’t see any evidence to support the superiority of ACE inhibitors for preventing end-stage renal disease in diabetes. It is, of course, entirely possible that I am missing something, due to not having read the work of Lu and Ades.

Next: “In participants with a history of admission for exacerbations of COPD, telemonitoring was not effective in postponing admissions and did not improve quality of life. The positive effect of telemonitoring seen in previous trials could be due to enhancement of the underpinning clinical service rather than the telemonitoring communication.” What a surprise. Is anyone listening?

GlaxoSmithKline used to be a baddy, but now Britain’s leading drug manufacturer is a goody—at least in terms of data release. As the excellent Peter Doshi, now an assistant editor at the BMJ, notes, “GSK has forged ahead with a new website enabling third party access to deidentified participant level data “because it is the right thing to do, both scientifically and for society.”’ The problem for GSK is that there are some skeletons in its cupboard. Ten years ago it was trying to encourage sales of paroxetine for teenage depression, on the back of study in adolescents numbered 329 which was reported as positive but was actually negative: and now an Australian team wants to analyze the complete data from this study. GSK are playing hard to get, which is understandable: this issue, as well as its concealment of data about rosiglitazone, contributed to its paying out $3bn for criminal fraud. But GSK needs to swallow its embarrassment: if the company wants to be seen as the Mr Clean of pharma, it should show contrition and just hand over the data.

Plant of the Week: Wisteria sinensis

November may seem an odd time to be praising wisterias, but in my view it is one of the three times in the year that these enormous climbers display their incomparable beauty. The first is of course in May, when those wands of bud open into cascades of fragrant flower. If you have a good cultivar, these flowers will cover the entire plant and be interspersed and succeeded by handsome sprays of brownish pinnate leaf.

Over the summer, your wisteria turns into a formidable Triffid, attacking your house and walls with innumerable whip-like growths, which you must keep under control by constant pruning. But if August is warm, you will find a new crop of flowers appearing—in shorter, stumpier racemes than those of spring, but just as fragrant.

And then comes late autumn. Those lovely leaves dangle in all shades of pale green and rich yellow, before the winds shake them all off.

When the leaves are gone, your wisteria is merely a skeleton. Now you must get out in the cold and up on a ladder, shaping the stems to your will and attaching them to your walls with new efforts of drilling and wire-laying.

That’s if you haven’t taken the easy way out, and grown your wisteria up a large tree. Do both. Every garden should have as many wisterias as it can possibly hold.