Alex Nowbar’s journal reviews—5 June 2020

Alex Nowbar reviews the latest research from the top medical journals.


Endemic bullying in US surgical training

Almost 7000 general surgery residents across the US were surveyed in 2019 to establish the prevalence of bullying. Two thirds reported experiencing at least one bullying behaviour, and 18% reported frequent bullying. The bullying was usually done by other surgeons, especially other residents, but also attending surgeons (consultants). The most commonly reported types of bullying were repeated reminders of mistakes and being shouted at. A major challenge in surveys of bullying is how bullying is defined. Some would argue that being shouted at isn’t bullying per se and that it depends on the context. However, surveys do measure what the participants perceive they have experienced, and that is probably what counts. Of those reporting frequent bullying, 61% reported burnout compared with 37% of those not reporting frequent bullying. This doesn’t necessarily mean bullying caused the burnout, but I’m sure it can’t have helped. Action is needed to reduce bullying behaviours as it seems to be worryingly widespread.


Chemo not a risk factor for death from covid-19

Lee and colleagues performed a prospective cohort study of 800 patients with active cancer and covid-19 presenting to 55 UK cancer sites. Over half had only mild covid-19, and 28% of the cohort died. Risk factors for death were the usual suspects: age, male sex, hypertension, and cardiovascular disease. There was no difference in death rates between those who had received cytotoxic chemotherapy in the previous four weeks and those who had not, even after adjusting for age, sex, and comorbidities (since patients who had received chemotherapy tended to be younger, for example). This is contrary to what one would expect. Of course, with observational evidence such as this, confounding cannot be excluded as a reason for the findings. For example, patients who had had recent chemotherapy might have been treated more aggressively when they had covid-19. Or perhaps, services that were able to continue to provide chemotherapy coexisted with units with better expertise and resources dedicated to covid-19. The lack of association between chemotherapy and death rates is good news, though, and the fact that this study was large and prospective does add to robustness of the finding.

Another covid-19 cancer cohort

Kuderer and colleagues analysed almost a thousand patients from 100 institutions across the US, Canada, and Spain with active or previous cancer and covid-19. Of the 928 patients, 43% had active cancer and 39% were receiving active cancer treatment. At analysis, 13% had died. Risk factors for death were age, male sex, smoking, Eastern Cooperative Oncology Group performance status, comorbidities, and active cancer (versus being in remission). Risk of death was not linked to cancer type or type of anticancer therapy, which corroborates the findings of Lee et al. The most important and robust message from this study is that active cancer was associated with an increased risk of death from covid-19, which supports the concept of shielding. However, the lack of association between death and cancer treatment supports continuation of treatments such as chemotherapy, which is at odds with the concept of shielding.


Better late than never?

Beigel and colleagues have brought us the randomised evidence of benefit in covid-19 we have been waiting for. They tested a 10 day course of intravenous remdesivir in a double-blind trial of over a thousand patients worldwide. The primary endpoint was time to recovery (not the original primary endpoint, which was going to be change in clinical status, but the change was made early on without knowledge of assignments or outcomes). The trial found that time to recovery was shorter in those who received remdesivir—that is, a median of 11 days to recovery, compared with 15 days in the placebo group. Lack of difference in secondary outcomes such as need for mechanical ventilation were disappointing, and it is unclear whether the drug will save lives (the trial is ongoing).

Alex Nowbar is a clinical research fellow at Imperial College London, UK.

Competing interests: None declared