Richard Lehman’s journal review—18 January 2016

richard_lehmanNEJM 14 Jan 2016 Vol 374
SDM: no looking back
104 There are two interesting Perspective pieces in this week’s NEJM, both about individualizing care. The first is about shared decision making and its difficulties. The author usefully sees these through the eyes of a physician who is just beginning her struggle with the realities of communicating risk while accepting that individuals have the right to choose, especially in the context of screening and long-term preventive medication. Shared decision making is a long journey, and it’s taking the medical community a long time even to get started. This is a reasonably good place to set off from. But beware: once you have started, you can never go back to your comfort zone. You are on a lifetime journey beyond it.

Taylorism v tailoring
106 The next piece—also open access—caught my eye with its title, “Medical Taylorism.” What is Taylorism? Basically, it is the opposite of tailoring. Forget fitting things around human beings. Looking at how business could be made more efficient, Frederick Taylor declared that “In the past, the man has been first; in the future, the system must be first.” Pretty well every management consultant brought in to health services takes this approach. I’ll just leave you with this delicious observation: “There is a certain hypocrisy among some of the most impassioned advocates for efficiency and standardization in healthcare, as Boston neurologist Martin Samuels recently pointed out. ‘They come from many different backgrounds: conservatives, liberals, academics, business people, doctors, politicians, and more often all the time various combinations of these. But they all have one characteristic in common. They all want a different kind of healthcare for themselves and their families than they profess for everyone else.’ What they want is what every patient wants: unpressured time from their doctor or nurse and individualized care rather than generic protocols for testing and treatment.”

Bariatric surgery for teenagers
113 Severe obesity in adolescents can bring out the worst in doctors. “Please don’t tell me I’m too fat doctor. Every doctor I meet tells me that first thing,” said one of them to me about 35 years ago, and I hope I have never done it since. Fat teenagers are not exactly unaware of being fat. Blame their parents if you like, but that doesn’t help them. Tell them to diet if you like, but that doesn’t usually help them either. Offer them surgery? That seems extreme, but their lifetime risk is extreme, and at least we know this works in the short term. “In this multicenter, prospective study of bariatric surgery in adolescents, we found significant improvements in weight, cardiometabolic health, and weight-related quality of life at three years after the procedure. Risks associated with surgery included specific micronutrient deficiencies and the need for additional abdominal procedures.”

More cancers than you thought
135 There is no such thing as fighting cancer. We have to fight cancers, one by one, and The Cancer Genome Atlas Research Network is gradually mapping how many there really are. This week they reveal the genomic truth about renal papillary cancers: “Type 1 and type 2 papillary renal-cell carcinomas were shown to be clinically and biologically distinct. Alterations in the MET pathway were associated with type 1, and activation of the NRF2-ARE pathway was associated with type 2; CDKN2A loss and CIMP in type 2 conveyed a poor prognosis. Furthermore, type 2 papillary renal-cell carcinoma consisted of at least three subtypes based on molecular and phenotypic features.”

Plastic costs: $100 v $0
146 A plastic mesh is a plastic mesh. A piece of clingfilm is a piece of clingfilm, unless it is marketed as a wound dressing. If the guy at the meat counter wraps your joint of beef in some plastic mesh, he doesn’t charge £75 for it. If your cheese is wrapped in clingfilm, that doesn’t add another £20. But if you repair a hernia using a small piece of mesh, the plastic costs $100+. Surgeons in Uganda, where many people live on less than $2 a day, noticed that there was an awful lot of plastic mesh around in the form of mosquito netting. Helped by two surgeons from Sweden, they tried using sterilized pieces of mosquito net for inguinal hernia repairs under local anaesthetic. Did these work as well as commercial mesh? Indeed they did. Did they cost anything? Effectively, no.

JAMA 12 Jan 2016 Vol 315
What’s this in the freezer?
142 It’s been known for several years that the best treatment for Clostridium difficile infection is stool transplantation, but it is still used less than it should be: a case of slow motion adoption, so to speak. This Canadian trial should knock down all barriers, whether aesthetic or logistic. Frozen and thawed stool in suspension delivered by enema was compared with fresh stool in 219 patients with C diff. Three stool donors sufficed to provide enough frozen material to treat 108 people. The cure rate for either method was around 85%, so it’s high time hospitals invested in suitably labelled freezers.

Bariatric surgery lifts depression
150 A useful meta-analysis scans the present state of knowledge about the mental health of severely obese people before and after bariatric surgery. Beforehand, about 19% are depressed and 17% have binge eating disorder. These conditions were not associated with the degree of weight loss following surgery, but surgery was consistently associated with postoperative decreases in the prevalence of depression (7 studies; 8%-74% decrease) and the severity of depressive symptoms (6 studies; 40%-70% decrease).

JAMA Intern Med Jan 2016
Vitamin D causes falls?
OL The “correct” dose and formulation of vitamin D for older people is an area of contention. Many over-70s fall below the threshold for insufficiency, and this seems to be associated with all sorts of poorer outcomes, not just in bone and musculoskeletal function but also in cardiovascular and cognitive domains. This dosing study took 200 men and women of mean age 78 with a prior fall and blindly allocated them to receive a monthly dose of 24 000 IU of vitamin D3, 60 000 IU of vitamin D3, or 24 000 IU of vitamin D3 plus 300 μg of calcifediol. The higher dose groups achieved higher levels of plasma 25-hydroxyvitamin D but paradoxically had more falls over a year than the lower dose group. The three groups were relatively small and this study cries out to be replicated with a larger population over a longer period of time.

NOACs, truthfulness & the FDA
OL In outcome trials of anticoagulation, group discontinuation rates can make the difference between superiority, equipoise, and inferiority. Thomas Marciniak, a retired senior Food and Drug Administration analyst who blew the whistle on a rosiglitazone study, here looks at how reported discontinuation rates in trials of novel anticoagulants submitted to the agency compared with discontinuation rates in the published trial reports. There are substantial discrepancies. A short commentary by Joe Ross argues the case for FDA submission data to be made public—something the European Medicines Agency is now trying to do with its own submissions, despite much poorly camouflaged lobbying from industry. The AllTrials effort needs to continue, newly armed with Ben Goldacre’s COMpare initiative.

Lancet 16 Jan 2016 Vol 387
Post-op breast brachytherapy
229 Although I’ve accidentally become involved with discussions about breast surgery outcomes recently, it’s hardly my area of expertise, and this German trial had slipped under my radar when it first appeared on the Lancet website three months ago. Thanks to mammography, there are now a lot of breast lesions classed as low-risk invasive and ductal carcinoma in situ. Most of these would never become truly invasive cancer, but in our present state of knowledge most women undergoing breast-conserving surgery for them are advised to undergo several weeks of fractionated whole-breast radiotherapy. This is not only inconvenient and exhausting but can also have effects on nearby tissues, including the heart. The alternative treatment tested for non-inferiority here is called accelerated partial breast irradiation (APBI) and delivers a lower total radiation dose locally over a shorter time to a more limited area. This study shows “non-inferiority”—but the term is meaningless in this context, partly because overall outcomes are so good. What a woman needs is a good explanation and a pictogram of the actual numbers involved—more local recurrences with APBI, but less hassle, less skin damage, and exactly the same disease-free survival and overall survival at a median follow-up of 6.6 years.

Does GA harm baby brains?
239 The question of whether general anaesthetic agents can harm the developing brain is not a trivial one, and this big study goes some way towards allaying fears. In Australia, New Zealand, Canada and the UK, babies needing hernia surgery in the first few weeks of life were randomised to have it under sevoflurane GA or remain awake under regional anaesthesia. At two years, they are showing no difference in neurodevelopmental outcomes.

AAA screening harms
Vinay Prasad’s recent BMJ piece about screening and overdiagnosis said all that is needed, so I won’t labour the point with this article about AAA screening for older men. The title and the last sentence will do. Title: “Harms of screening for abdominal aortic aneurysm: is there more to life than a 0•46% disease-specific mortality reduction?” Last sentence: “Before implementation of screening, there is a burden of proof for both its benefits and its harms. In screening for aortic abdominal aneurysm, this burden has not been shouldered.”

BMJ 16 Jan 2016 Vol 352
A few weeks ago, I wrote a Plant of the Week section in praise of the potato. I admitted that potatoes are obesogenic, and that I don’t deny that obesity can cause type 2 diabetes and increase the risk of gestational diabetes. But here’s a paper comparing self-reported potato consumption in the US Nurses’ Health Study II data (1991-2001) with the incidence of gestational diabetes in the 15,000+ nurses who got pregnant over the following ten years. At this point I would have told the investigators to hang on and consider the shortcomings of this methodology and the need for a confirmation cohort, but they went ahead. Now the humble tuber stands accused of being a possible risk factor for gestational diabetes after correcting for BMI and other risk factors. The Chief Medical Officer must step in and ensure that pre-conceptual care includes a warning against potatoes. The credit cards of every woman filling in a Mat B1 should be tracked for potato-related supermarket purchases. This is a public health issue and deserves a suitably disproportionate response.

Here’s another observational study that could do with replication in another cohort. This time the criminal substance is clarithromycin, as prescribed to the people of Hong Kong. According to this analysis of data covering health provision to 7 million people in HK, during the days they took clarithromycin they nearly doubled their risk of myocardial infarction, and increased their risk of arrhythmia and cardiac death. Time to look at the CPRD and the Taiwan population, or perhaps just to withdraw clarithromycin from the market, since there are plenty of alternatives. Or else you could take the view that any individual’s chance of having a MI in any given week is so low that you can share the information and let them take the risk if they want to.

Plant of the Week: nothing

I’ve just been for a 2 mile walk through the woods of Connecticut. The trees were bare. The ground was bare. But it was nice to the streams flowing and remember how these places looked in spring and autumn.