Richard Lehman’s journal review—22 September 2014

richard_lehmanNEJM 18 September 2014 Vol 371
1100  The way I have ureteric colic is so classical that just watching me sweat and groan is enough for anyone to make the diagnosis, even without the haematuria on the dipstick. I see the same thing all the time in out of hours primary care patients, and generally get the diclofenac injection drawn up after about two sentences of history taking while I dip the urine. I can’t remember ever having to refer anyone for acute imaging. But somehow acute nephrolithiasis manages to cost the US healthcare system $2bn a year, and it seems that most patients are investigated with an immediate abdominal CT. This is a dangerous procedure, partly because of the radiation load, but even more because of all the incidental findings that are bound to turn up. A large American trial compared CT with point of care ultrasound or full formal ultrasound. “Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations.” I suspect that if they had had a no-investigation arm, the results would have been the same.

1111  Sucking clots out of coronary arteries at the time of myocardial infarction sounds like a good idea, and the single centre TAPAS trial, published in 2008, reported a 40% reduction in all cause mortality at one year. Unfortunately it was not designed to measure this outcome, whereas the much bigger Swedish TASTE trial, reported here, was properly powered and better randomized. And would you know it, routine thrombus aspiration before PCI in patients with STEMI did not reduce the rate of death from any cause or the composite of death from any cause, rehospitalization for myocardial infarction, or stent thrombosis at one year.

OL  The ADVANCE trial was one of the three published in 2007-8, which showed that intensive glucose lowering in established type 2 diabetes had no benefit on hard outcomes. But it was a complex factorial trial, and it also measured the effect of blood pressure lowering in this patient group using a fixed combination of perindopril and indapamide. Once the trial was completed, glucose and blood pressure control in all the groups quickly became similar. So this long term follow-up study is really measuring a “legacy effect” of the tighter control which was imposed many years ago (the median post-trial follow-up period is 5.9 years for blood pressure and 5.4 for glucose). There was no evidence that intensive glucose control during the trial led to long term benefits with respect to mortality or macrovascular events. But the odd thing is that, in contrast with other studies, the tight blood pressure group in this trial does show a small persisting mortality benefit.

JAMA 17 September 2014 Vol 312
1105  For a very brief period in my early adolescence, I was high priest of a cult which worshipped magnesium. The ritual, performed in the school lavatories, consisted of my putting a lighted match to a strip of magnesium ribbon, which burnt with a blinding light while we all intoned the chant “Maggi! Maggi!” We then dispersed, spiritually refreshed to face the evils of another day at a northern grammar school. But after a few days, we spotted the dread figure of Flinky, the deputy headmaster, striding with gown afloat to investigate the pall of white smoke arising from the bogs. We dispersed quickly, like Early Christians spotting a Roman commander with a lion. It were grim up North: Hogwarts had nothing on King Edward VII School in Sheffield, circa 1963. I tell you all this in a vain attempt to bring interest to a paper whose conclusion is: “Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeks’ gestation was not associated with neurological, cognitive, behavioral, growth, or functional outcomes in their children at school age, although a mortality advantage cannot be excluded. The lack of long term benefit requires confirmation in additional studies.”

1114  “And then there’s me inhalers doctor.” Visiting a breathless elderly patient at home, you can tell what’s coming: tiotropium and a combination of a steroid and a long acting beta-agonist (LABA). Causing chronic β-adrenergic overdrive in people with chronic pulmonary obstructive disease may well hasten their death, and although many of them may want this, it is not a respectable endpoint for selling drugs. So it has become customary to add an inhaled corticosteroid to the LABA to counteract its deadly propensities. This also has the advantage of keeping branded, fixed dose combinations at the top of the drug sales charts. In fact, many COPD patients have a degree of ventricular overload and live longer if they take β-adrenergic blocking agents. Oh well, mustn’t argue with usual practice. A new Canadian propensity matched cohort study shows that: “Among older adults with COPD, particularly those with asthma and those not receiving a long acting anticholinergic medication, newly prescribed LABA and inhaled corticosteroid combination therapy, compared with newly prescribed LABAs alone, was associated with a significantly lower risk of the composite outcome of death or COPD hospitalization.”

1136  I’ve just attended the Preventing Overdiagnosis conference in Oxford and I am filled with reforming zeal. So I bridled at the title of this clinical review: Evaluation and Treatment of Older Patients With Hypercholesterolemia. No! and again No! They are people not patients, and there is no such thing as “hypercholesterolemia,” any more than there is such a thing as “hypertension”—there are just continuously distributed variables, which contribute to overall cardiovascular risk. But I was mollified when I read their sensible conclusion: “No RCT evidence exists to guide statin initiation after age 80 years. Decisions to use statins in older individuals are made individually and are not supported by high quality evidence.”

Lancet 20 September 2014 Vol 384
1099 In a pep talk I gave to a group of GPs a couple of days ago, I pointed out that nearly every week somebody reports a complex interventional trial done in the UK with “usual care” as the comparator, and almost none of them show that the complex intervention is better. Our noble College, if it had any sense, would hail each one of these as a triumph for UK general practice. Despite the intolerable struggle with diminished resources and imposed agendas of futile work, we still manage to provide care that is generally as good as any model parachuted in by academics and “experts.” But that does not apply to depression in patients with cancer, according to this report of a multicentre, randomised controlled effectiveness trial of integrated collaborative care in Scotland. The programme was systematically delivered by a team that comprised cancer nurses (trained to competence in depression care for people with cancer) and supervising consultation-liaison psychiatrists, working in collaboration with the patient’s oncology team and primary care physician. In other words, it was the kind of care that everybody should have access to but does not, even in a relatively favoured part of the NHS like Scotland. It seems to me that the key components were prolonged human support and shared communication. But to get access to these you needed the label “cancer.” The trial randomized 500 patients with a cancer diagnosis, of whom just 34 died of cancer “during the period of the trial”—which could mean 24 or 48 weeks, but is in any event startlingly low. Ninety three per cent of these cancer patients were by no means on the verge of death but nearly half of them were depressed, and having the cancer label got them access to an extra £613 worth of care, which gave them an eight fold better chance of improvement. Someone should write an essay on “The Advantages of Having Cancer”—not to grudge one particle of these—but to ask why cancer among all life shortening or threatening illnesses should be the only one to enjoy proper levels of public sympathy, charitable support, access to supportive and palliative care, government benefits, and research funding.

1118  Putting talc powder into the pleural space is a simple technique, which dates back to the days of tuberculosis and sanatoria. Contrast this with video assisted thorascopic partial pleurectomy, using the latest in sophisticated technology. The BUPA Foundation did the trial in malignant pleural mesothelioma, and discovered that talc pleurodesis “might be preferable considering the fewer complications and shorter hospital stay associated with this treatment.”

1095  It comes as a surprise to me that the Lancet will publish anything with my name on it, but John Yudkin has very kindly sneaked me in as co-author of a letter about cardiovascular outcome trials of glucose lowering strategies in type 2 diabetes. At the time of writing, this correspondence stream seems to have escaped the Elsevier paywall and I would urge you to read it if you can. A response from Rury Holman and colleagues seems to herald a new era of peace and collaboration in finding out the real effects of blood glucose lowering agents. This is exactly what people with diabetes need, and we should seize the opportunity.

The BMJ 20 September 2014 Vol 348
“By including our users in our product development, we are able to deliver solutions that drive high quality healthcare,” says the BUPA website. No sorry, must be Medtronic. Oops no, it’s the BMJ. So sorry. Here are some of this week’s high quality healthcare driver solutions:

Screening was a major theme at the Preventing Overdiagnosis conference. I didn’t see Tony Delamothe there, probably because he was writing his editor’s choice “I wake up screening.” The first major screening programme to get underway in most countries was aimed at preventing cervical cancer using “Pap” smears. This carries a huge burden of overdiagnosis, but at least we know a lot about it. And, recently, we have been finding out a lot more about the role of human papillomavirus and testing for that instead or as well. And now there is a urine test for HPV, which shows quite good predictive agreement with cervical HPV testing. Trouble is, the only true test of these diagnostic modalities is their power to determine treatments that eliminate cervical cancer: and we have a long way to go before we know about that.

An associational study links benzodiazepine use (and its duration) with risk of Alzheimer’s disease. It has all the difficulties of such studies, and this one generates a hypothesis which can’t be solved by a randomized controlled trial. We could, however, look at a similar study of serotonin reuptake inhibitors, perhaps. Benzo-bashing is all very well, but we know far too little about the potential harms of most long term psychotropic treatment.

While at the conference, I was struck by the number of people who volunteered that they had given up using the term “hypertension” and were keen to see it abolished. I think we should form a Society for the Abolition of Hypertension. Here is an article about mild hypertension in people at low risk that goes some way to explaining why, accompanied by an article by a patient who is fazed by all these seemingly random changes of medical opinion. Take any cardiovascular risk factor, and you see a fairly linear relationship between its level and the degree of risk. Then you put in an intervention that lowers the risk factor. Sometimes it lowers the risk. But in all cases there comes a point where the “disutilities” of the treatment outweigh any benefit, or no benefit is observed at all. At a population level, the treatment may postpone a particular form of mortality, but have no effect on overall mortality. We live a while and then die. We all want to live well, and sometimes have preferences about the way we want to die. So we should all judge for ourselves what treatment we take, based on the likelihood of personal benefit or harm. Nobody suffers from hypertension, but a lot of people suffer from the effects of treatment to lower blood pressure.

Plant of the Week: Anemone x hybrida “Honorine Jobert”

“Traveller’s Joy” is the name given to our massive native clematis, C vitalba, which forms immense lianas and covers high trees in such fabulous spots as the Wye Valley near Tintern, or the wooded Undercliff area above the Jurassic Coast in Dorset. But for the suburban motorist, cyclist, or pedestrian in August and September, the true traveller’s joy comes from the Japanese anemones, which flower almost wild in many a suburban front garden.

The pink ones come in various shades and come single or double. Nearly all are good. But the very best, in my view, are the single whites. The one that’s sold everywhere is called “Honorine Jobert,” no doubt after some admirable example of French womanhood. Perhaps she was a tall willowy beauty who danced in the breeze, like these anemones. They start flowering in early August and never look tired or brown, and, as the season draws to a close, they just grow taller and more beautiful, carrying shining white flowers with yellow stamens at a height which can exceed a metre.