Richard Lehman’s journal review—4 July 2016

richard_lehmanNEJM  30 Jun 2016  Vol 374

Cervical sense

2509   This week’s NEJM is an odd mix of the down-to-earth and the arcane. The down-to-earth comes first, ahead of midostaurin for advanced systemic mastocytosis, PD-1 blockade in Merkel-cell carcinoma and deficiency of sFRP4 as the cause of Pyle’s disease. If these conditions did not exist, it would be necessary for the New England Journal to invent them. Meanwhile, in the great world outside the Massachusetts General Hospital, hundreds of thousands of women die avoidably each year from cancer of the uterine cervix. Here’s a really clear short open-access piece describing why and what we could and should do about it instead of destabilising the world in a series of fantasy games.

WHO will do the obvious for diagnostics?

2511   In that perspective piece on cervical cancer, a major theme is the lack of basic diagnostic test facilities in low-to-middle-income countries. That’s the subject of the next open-access article. “The Model List of Essential Medicines (EML) maintained by the World Health Organization (WHO) plays a central role in global health policy. We believe that it’s time to establish a similarly influential Model List of Essential Diagnostics (EDL).” Why do I despair of even such an obviously necessary thing happening in the next five years? How is it that I’ve reached 66 only to be stranded in a world without grown-ups to run it?

Hand over that baton

2514   The third perspective piece (not open-access) is about harnessing the value of older scientists. I can’t really call myself a scientist, though I believe passionately in the basic principles of science. If there’s one baton I’d like to hand over, it’s Nullius in Verba, the 1665 motto of the Royal Society. Don’t Take Their Word For It: if only the NEJM would blazon that on its front page. But this article has nothing to say about that. In the USA, investigators can hang on to their posts forever, and the authors just suggest that maybe they should get out of the way and encourage the young instead. They should.

Calcium pyrophosphate deposition disease

2575 “Calcium pyrophosphate deposition (CPPD) disease is arthritis caused by calcium pyrophosphate (CPP) crystals.” Light dawned. CPPD was not another recherché condition to be discussed only within the walls of Bostonian medical enclaves but something I once used to diagnose and treat in a single ten-minute consultation. A woman of 73 might limp in and say that her knee used to creak a bit and hurt on the stairs but now it had swollen and she could hardly walk on it. In went the needle and out came some joint fluid for the sample bottle. Then in went some lidocaine through the needle, followed by triamcinolone. The report came back a week later reporting birefringent crystals and the lady came back walking better. Sorted. Next. As a friend recently tweeted, “Some patients don’t need narrative justice/ empathy, /cod Freudian analysis etc. some just want analgesia or a diagnosis.” Pseudo-gout is a very satisfying diagnosis to make, though it can be a pain to live with. I think this article is right in suggesting that it is very often missed.

JAMA 28 Jun 2016  Vol 315

The idolatry of new technology

2659   “The adoption of costly prostate cancer therapies, such as proton beam therapy, robotic-assisted radical prostatectomy, and intensity-modulated radiation therapy, has been driven by the idolatry of new technology, direct-to-consumer advertising, and fee-for-service medicine, in the absence of high-level evidence or device registries.” I fancied that I might have played some part in bringing the word “idolatry” into medical parlance around 2013, but I discover that JAMA got there first in an article about “gizmo idolatry” in 2008. In that article they talked about pulmonary artery pressure monitoring, and in this one different authors talk about high-intensity focused ultrasound (HIFU) for prostate cancer. You put the ultrasound probe into the rectum and use it to precision-roast biopsy-positive areas, suspicious areas on multiparametric magnetic resonance imaging (mp-MRI), or both. The trouble is that although it sounds high-tech, the actual situation inside the prostate can still be a bit of a mess: areas of malignancy are easily missed or undertreated, while any stray damage to the capsule can cause very unpleasant complications. It’s all beautifully explained in this commentary piece, most of which you can read without a subscription. Once again, the standard of practice needs to be: lay out the true benefits of HIFU (if any are known to exist) versus the potential harms (as listed) in a simple infographic, and see how many men decide to have it. Then follow up every volunteer carefully. If you don’t do this, you are experimenting on human beings without their fully informed consent and without learning from what happens to them. And yet it happens all the time, everywhere, in most specialties, and for big money.

Get SPRINTING at 80?

2673    Controversy about whether to treat high blood pressure in the older old has dogged me since medical student days. In 1973 we were told that giving people BP lowering drugs past the age of 75 was likely to do more harm than good, since they needed a higher pressure to perfuse their brains and would probably fall over if you tried too hard to reduce it. Opinion has swung back and forth over the decades, but recently a broad consensus seemed be moving again towards looser systolic targets in older people. Certainly in my own experience it was often very hard to get old people under SBP 160 without making their lives miserable with adverse effects and polypharmacy. But now along comes this big subgroup study from SPRINT, suggesting that 120 should be the target for reasonably fit people aged 75 and above. This would mean giving blood pressure medication to 75% of this population, to achieve a reduction in cardiovascular events of 30%, and some prolongation of life. Someone needs to come up with an infographic based on SPRINT to help people to decide for themselves.

Escitalopram, heart failure & depression

2683   As heart failure progresses, people with it become more depressed. In fact a depression score probably has about the same prognostic accuracy as serial measurements of BNP. There are plenty of psychosocial reasons for this, and plenty of physical reasons too, including feel-bad chemicals released all over the under-perfused body. Serotonin reuptake inhibitors are supposed to combat these. But in this German trial (MOOD-HF), 18 months of treatment with escitalopram in patients with systolic HF and depression did not significantly reduce all-cause mortality or hospitalization, and there was no significant improvement in depression compared with placebo. These sad, dying people need a different kind of care.

JAMA Intern Med  June 2016

Family-reported life endings

OL   Many sad, dying people need a different kind of care. Here’s an important open-access contribution to the palliative literature which needs to be read both for its message and its methods. OK, it’s set in the USA, where levels of futile invasive care at the end of life are very high by British standards. But the overall result is probably transferable: “Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with end-stage renal disease, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders…” This gives rise to a thoughtful open-access commentary piece, beginning “There is often a fog that descends on patients, families, and healthcare professionals when they are navigating the difficult situation at the end of life. There is a lack of clarity regarding the trajectory of the illness, the true burdens and benefits of the myriad interventions, and how best to integrate palliative care into the overall care plan.” Family-reported quality of end-of-life care is an important metric, but not without its difficulties, as this commentary points out. And the challenge is not so much to measure as to improve, as two great recent pieces by Scott Murray in The BMJ have made clear. The latest is a must-read Personal View about his own experience.

Shared decision making & cancer teams

OL   In this blog and in other places, I’ve often expressed my concern about the quality of shared decision making in oncology teams. This is made painfully clear in a piece by Brian Klepper about his wife’s last months with peritoneal cancer.

His narrative inspires a thoughtful commentary about the need for true shared decision making in oncology teams, based on the best current evidence about treatment options in this fast-moving field. We urgently need every paper about a new oncology drug trial to incorporate a comparative infographic, compiled by an independent author from the individual patient data. This could probably be done for the same cost as a single course of the treatment. But we also badly need to develop good models of team shared decision making where the patient’s voice can be heard above the din of technical debate, as the expert of final choice.

Lancet  2 July 2016  Vol 388

All Caesars are equal

62    The initial results of the CORONIS trial appeared three years ago and showed that several varieties of Caesarian section technique made no difference to short-term maternal outcomes when randomly applied in several low-to-middle income countries. Now, at an average follow-up of 3·8 years, no significant differences have appeared in long-term outcomes, including pelvic pain, deep dyspareunia, incisional hernia, intra-abdominal adhesions, outcomes of subsequent pregnancies, hysterectomy, and the morbidity and mortality of children. Hail Caesar.

CT for the smashed up

OL  At four hospitals in the Netherlands and one in Switzerland, 1403 seriously injured patients were randomised to get immediate whole-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. The REACT-2 trial ended in equipoise. There was no difference in in-hospital mortality between groups, and the total-body CT group received more radiation.

The BMJ  2 July 2016  Vol 354

The spectre of spectrum bias

Here’s a lesson on the spectrum effect in tests for risk prediction, screening, and diagnosis, from the department of primary care at Cambridge. Don’t turn the page. This is one of the most fundamental things to grasp for any medical practitioner, especially if you’ve forgotten what the spectrum effect actually is. Like most stats terms, it’s almost designed to be forgettable: the spectrum referred to is the spectrum of people with the condition of interest. So what it means is that the predictive characteristics of whatever test you use will depend on the population you are looking at. Very few tests approach predictive perfection, and the less common the condition in the people you are testing, the more likely that your test will be a false positive. Typically there is quite a wide spread. For example, the performance of an exercise test for coronary artery disease varies across patients with different characteristics; the positive likelihood ratio is 3.8 in individuals with systolic blood pressure 141-240 mm Hg, and 17.0 in those with systolic blood pressure 100-140 mm Hg. But I won’t go into detail. Get the paper and do your revision please. If you don’t understand this stuff, what hope have you of getting your patients to understand it?

Press lies and bad decisions

What if the front pages of the Daily Mail and Express shrieked misinformation? If even the more respectable organs of the press gave mixed messages? The British people might think “sod it, these experts don’t know anything,” and decide good riddance, it’s time we took back control and severed links with our statins. Say that many Britons were then seized with decisional regret. But under Article 51 of the Statins Treaty they could never go back to taking them. What an idiotic situation that would be. It couldn’t happen in real life. People would insist there was sensible shared decision making based on the facts. Now it seems, on the basis of figures from the CPRD about the prescribing of statins in the UK, that there may have been a drop in statin-taking last year. This followed several sceptical pieces about statins for which The BMJ took some blame. A while after this, people started taking statins again – which is a common background phenomenon. The main good to come of it all is a superb editorial by Gary Schwitzer on the shortcomings in press coverage of nuanced issues. I hope he can be made Minister for the Abolition of Lies ahead of a repeat EU referendum.

Plant of the Week: Campanula cochlearifolia “Elizabeth Oliver” 

Our little gardens are nearly full up now, though spaces often appear due to unprogrammed deaths. One of the saddest was that of a lovely little campanula called Elizabeth Oliver some years ago. I suspect I may have treated her too roughly, in too much of a hurry to make new plants of her all over the garden. She’s a little joy, creating a mound of double flowers of pale but distinctive pure blue over a long period. Unfortunately all the nurseries we normally visit no longer stock her. I guess we may have to resort to mail order.

There are others of this species which are also very good for filling all the little spaces at the front of edges and borders where bare soil is still showing. The most charmingly named is “Tubby” with fatter flowers of a darker blue than Elizabeth’s.