Richard Lehman’s journal review—12 May 2014

richard_lehmanNEJM   8 May 2014  Vol 370
1799   The idea that malaria was spread by mosquitoes was first mooted in the 1870s, but it took twenty years to work out what really went on in the parasite’s life cycle. As far as I can tell, this was first achieved by Giovanni Batista Grassi, though Ronald Ross claimed the credit and got the Nobel Prize in 1902. By now we should know everything about malaria, and the disease itself should have been consigned to history. But this paper proves that is far from the case. It is an observational study of severe Plasmodium falciparum malaria in Tanzanian children. Like Manson, Grassi and Ross, these investigators took a lot of blood samples from subjects with malaria. What they found is somewhat of an enigma. Severe malaria in children is not linked to individual parasite burden. Mild malaria does not protect against severe malaria. There are some strange parasite-host interactions going on which do not obey the usual rules of immunology. If this sort of thing intrigues you, the full paper is free online.

OL   Urinary infection and vesicoureteric reflux in children is another area where I feel slightly lost. But it seems I am in good company: the editorial on the latest trial (RIVUR) concludes that “Sadly, the decision to use antibiotic prophylaxis in children with reflux remains a clinical dilemma, despite this well-done study.” The well-done study randomized 607 children aged 2 to 71 months of age and had grade I to IV vesicoureteral reflux to receive either placebo or continuous antibiotic prophylaxis with co-trimoxazole for 2 years. At the end of this period, the active group had accumulated significantly fewer infections, but this was not reflected in a lower rate of renal scarring. Over the years, I have heard paediatricians become dogmatic on this subject, but here is more evidence that whatever we do makes very little difference to most kids with reflux. Just keep a sharp eye out for urinary infection whenever they become febrile.

JAMA  7 May 2014  Vol 311
1770   Another subject that always makes me feel stupid is heritability. “Among children born in Sweden, the individual risk of ASD and autistic disorder increased with increasing genetic relatedness. Heritability of ASD and autistic disorder were estimated to be approximately 50%.” ASD, by the way, here stands for autistic spectrum disorder, as distinguished from autistic disorder. Let that pass: the key issue is how you define “heritability” as a quantitative concept. As usual, Wikipedia comes to the rescue: “The heritability of a trait within a population is the proportion of observable differences in a trait between individuals within a population that is due to genetic differences.” OK, I get that. But then it goes on to say, “Heritability measures the fraction of phenotype variability that can be attributed to genetic variation. This is not the same as saying that this fraction of an individual phenotype is caused by genetics.” It looks as if I need a bit of time here. So go away, you lot: I don’t need you watching me work this out. You must have better ways of passing an afternoon.

1778   The next article deals with the prevalence of type 1 and type 2 diabetes in children and adolescents in the USA between 2001 and 2009. Now here is where I can show off: I know what prevalence means. I also know what incidence means. And I don’t need to be told that in the case of diabetes, both are going up. I want a nice simple graph showing me how much they are going up and if the curve is flattening or steepening. But this article doesn’t have such a graph, just some tables of prevalence. Pah.

Ann Intern Med  6 May 2014  Vol 160
585   I haven’t reported anything from the Annals for a while, but that doesn’t mean I have stopped looking. There just hasn’t been that much to interest a UK generalist. And this article called “Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study” may not be that riveting if you have no interest in the US health system; but some of us have. The Massachusetts 2006 health care reform has been called a model for Obama’s Affordable Care Act, and we all need Obamacare to succeed, because while ever the USA has the most distorted, expensive and dysfunctional health system in the world, we all suffer from the bad models that emanate from it. This study was not in any way “quasi-experimental”: it’s just an observational comparison between what happened to mortality rates before and after reform in Massachusetts, as compared with a control group with similar demographics and economic conditions living in other states. Massachusetts did better, and the poorest benefitted the most. Republicans who voted in the Massachusetts reforms have something to be proud of. As for the rest, who have tried everything to wreck Obamacare, I can only feel a sort of incredulous contempt.

Lancet  10 May 2014  Vol 383
A dismal phase 2 trial of a new analgesic in post-herpetic neuralgia (an angiotensin II type 2 receptor blocker, would you believe) and two big surveys of social problems fill up The Lancet‘s research pages this week. Look for interest in the reviews.

1665   There was once a pale scrawny kid raised by Polish asylum seekers living off state benefits who did not get rickets. No doubt I deserved to, but Mr Bevan’s new socialist Health Service gave me free bottles of cod liver oil and sessions walking around ultraviolet lights with a bunch of other scrawny poor kids. I have been left with a terrible sense of entitlement and dependence on the State ever since. The sad fact is that rickets—clinical and subclinical—is on the rise in the UK again. And this review comes to a very radical conclusion: “Rickets is a preventable disease and prevention should start in pregnancy… We believe that until growth ceases supplementation at 10 μg per day (400 IU per day) in all individuals, except those with a known contraindication (eg, hypercalcaemia or sarcoidosis) should be recommended and that, without such a programme of supplementation and concurrent public health campaign, the incidence of rickets will probably continue to rise.”

1677   A couple of weeks ago I stupidly missed the opportunity of hearing Iain McGilchrist give a talk called “Spiders yes, but why cats?” This was all about the imagery in pictures painted by people with schizophrenia. The point of his talk—of which I hear brilliant reports—was that it is easy to understand why images like spiders occur in the imagination of people with psychosis, but their entrancing depictions of cats recur again and again and are much harder to account for. And they occur in the poetry of schizophrenia too, as anyone who has read Christopher Smart’s Rejoice in the Lamb will know:
“For I will consider my Cat Jeoffrey.
For he is the servant of the living God duly and daily serving him…
For he keeps the Lord’s watch in the night against the adversary.
For he counteracts the powers of darkness by his electrical skin & glaring eyes.
For he counteracts the Devil, who is death, by brisking about the life.
For in his morning orisons he loves the sun and the sun loves him.
For he is of the tribe of Tiger.”
(excerpt from several hundred lines about Jeoffrey, his companion in confinement for lunacy,1759-63, first published 1939)

From Smart to the current “science” of schizophrenia is a rather dismal journey. Just in the last three decades theorizing has switched from neurotransmitters to genetics to cognitive models and back again. This review tries to marry these various models. When they can account for the cats, we’ll know they are getting warm.

BMJ  10 May 2014  Vol 348
An excellent Dutch trial of helmet therapy for babies with misshapen skulls at 5-6 months finds that after two years, a quarter of skulls in the helmet group have achieved “full recovery,” which is the same as in the control group. This is a misuse of the term “recovery” since that would mean they had gone back to exactly as they started. And what is a “fully normal” skull anyway? The investigators argue that this shows that helmets are a useless encumbrance. They cannot be the “helmet of salvation” famously alluded to by St Paul the Apostle. Ah, but not so fast, reply the advocates of baby headwear in the Rapid Responses. Can you guess their arguments? Yes, that this study proves that skull deformities persist, so more not fewer treatments are need. Parents should flock to clinics like their own to be assured of better fitting-helmets. And the helmets need to be fitted in the first weeks of life. You have this on the authority of (inter alia) Timothy R Littlefield , MSEng, Vice President, Research and Regulatory Affairs, Cranial Technologies, Inc., Tempe, Arizona, USA.

I was taught English in a northern British grammar school in the 1960s. This makes a me a bit curmudgeonly about much medical prose, especially from America. Consider this latest BMJ submission from Harvard: ” Lower risks of measured outcomes likely reflect unmeasured differences in comorbidity and frailty. The findings highlight potential pitfalls of observational comparative effectiveness research and support physician consideration of general health status in selecting patients for ICD therapy.” By spending a year in New England I’ve grown used to listening attentively to this kind of stuff and translating it as I go. “Likely” means “probably.”  “Measured outcomes” means “recorded adverse outcomes.” The second sentence jumbles unrelated concepts. “Findings highlight potential pitfalls” is the sort of phrase that would have led to corporal punishment in my day. We were taught that writing was the organization of thoughts and words so that they followed a logical order and rhythm that would make them understandable. I can’t find any connection between the first and second parts of this sentence. If the findings show that important data about comorbidity and frailty are (likely) missing or unrecorded, how does that help physicians take them into account when selecting patients for ICD? And what is this “when selecting patients” about: shouldn’t that read “when discussing ICD implantation with patients?” This is paternalistic shared decision making at its traditional worst: the physician makes the decision on the basis of lousy evidence and the patient shares it.

Plant of the Week: Ranunculus bulbosus “F.M.Burton”

At this time of year, and indeed for some months yet, English meadows are full of buttercups. They look happy, even on rainy days. But woe betide the gardener who allows this happiness in the formal garden. The buttercup is ruthless, and its children will soon be everywhere, forming tough root systems that sucker and spread.

Such—I am told—is not the case with Ranunculus bulbosus, a non-invasive buttercup which in the form of “F.M.Burton” bears cup of soft primrose yellow. “Easy in moist or normal soil, shade. Lovely. H7 (below -20)” says the label. Sounds like a plant that might even thrive in Connecticut.