{"id":26358,"date":"2013-05-13T13:42:34","date_gmt":"2013-05-13T12:42:34","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=26358"},"modified":"2013-05-20T13:41:35","modified_gmt":"2013-05-20T12:41:35","slug":"richard-lehmans-journal-review-13-may-2013","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2013\/05\/13\/richard-lehmans-journal-review-13-may-2013\/","title":{"rendered":"Richard Lehman’s journal review\u201413 May 2013"},"content":{"rendered":"

\"RichardJAMA\u00a0 8 May 2013\u00a0 Vol 309<\/strong>
\n1903\u00a0\u00a0\u00a0 When an implanted cardioverter defibrillator goes off inside you, you are sure to feel deeply shocked: whereas, for others, watching you drop dead might be even more shocking. One needs to strike a balance. That was the purpose of the ADVANCE III (Avoid Delivering Therapies for Nonsustained Arrhythmias in ICD Patients III) trial<\/a>. Essentially this was a gamble on how many ventricular tachycardia beats are allowed to happen before the device fired: with current devices it is usually 18-24, whereas in this trial half the patients got a newly programmed device which counts to 30-40. They stayed alive as much, didn\u2019t have more syncopal episodes, and had a third fewer shocks in the first year.
\n<\/p>\n

1912\u00a0\u00a0 I thought that every human being in the state of nature carried Helicobacter pylori<\/em>, but I was wrong: about 5-10% of the human race never harbour the bug, no matter how much they are exposed to it. This paper reports on two studies<\/a> which identify the genotypes of these helicobactrophobic individuals in Pomerania and in Rotterdam. The investigators confess that they cannot think of any use for this knowledge at present; but in the great scheme of things it may come in handy one day; which no doubt is why JAMA<\/em> decided to share it with us.<\/p>\n

NEJM\u00a0 9 May 2013\u00a0 Vol 368<\/strong>
\n1771\u00a0\u00a0\u00a0 Haematological cancer is not my specialty, or yours, in all likelihood. We don\u2019t have to decide when to give platelet transfusions, but those who do have found over the years that they can safely wait until the platelet count has gone down to 10×109<\/sup> and then give half as many platelets as they used to. The next step would be to give none at all until a bleeding event occurs, and that was the strategy tested in this Australo-British trial<\/a>. But it was a step too far: the rate of serious bleeding in the no-prophylaxis group was only modestly higher (by 8%) but their bleeds came sooner and lasted longer.<\/p>\n

1791\u00a0\u00a0 I saw the title and expected a good observational study: Respiratory Syncytial Virus and Recurrent Wheeze in Healthy Preterm Infants. And there is certainly plenty of good observational data in this study<\/a>; but essentially it is a trial of palivizumab, an anti-RSV agent manufactured by Abbott, in preterm infants, with a primary outcome consisting of the total number of parent-reported wheezing days in the first year of life. So the title should really have been \u201cPalivizumab injections to prevent wheezing in the first year after preterm birth.\u201d I don\u2019t know if reprint-selling disease has spread to the titles of NEJM<\/em> articles, but it looks that way to me: we\u2019ll never know how many copies of this paper get bought up by Abbott or how they might be used to promote sales of palivizumab, because the NEJM<\/em> considers that commercially confidential. The economics of palivizumab were discussed in a BMJ<\/em> piece in 2009: a course of RSV prophylaxis costs between \u00a33-5K in the UK. It\u2019s estimated that at least 60% of babies get RSV in the first year of life. In the great majority it is a mild illness, though some get bronchiolitis and may then wheeze after each subsequent upper respiratory tract infection; by the age of three hardly any do. So it\u2019s hard to put a price on a 60% reduction in first-year wheezing days: a happy outcome, certainly\u2014but worth spending \u00a33-5K on every baby born at 33-35 weeks\u2019 gestation?<\/p>\n

1800\u00a0\u00a0\u00a0 They\u2019re at it again! Crunching up thousands of tons of lovely oily fish and turning them into capsules of n-3 fatty acids. These were then fed to Italian \u201cmen and women with multiple cardiovascular risk factors or atherosclerotic vascular disease but not myocardial infarction<\/a>. Patients were randomly assigned to n\u22123 fatty acids (1 g daily) or placebo (olive oil).\u201d Maybe 1G of olive oil is just a placebo: certainly for an Italian. Anyway, there was no difference at 5 years. To derive any protection, you have to eat the fish as well as the oils. Turbot is the best fish for n-3 fatty acids, I\u2019m told: excellent as steaks or fillets fried in butter and served with a sauce of reduced cream, white wine and morels (or since you probably lack morels, some fresh chopped sorrel at the last minute); or just a simple hollandaise. The point of all fish is the butter that goes with them. There are those who assert that the quantity of butter should equal the quantity of fish, but I think that this should be left to the conscience of the individual believer.<\/p>\n

1817\u00a0\u00a0 Here\u2019s a really comprehensive review of enteropathogens and chronic illness in returning travellers, which makes you wonder what we\u2019re missing in some of these unfortunates. The GeoSentinel Surveillance Network gathered data on 25,867 returned travellers over a 9-year period<\/a> (from 1996 to 2005). \u201cOf the 2902 clinically significant pathogens that were isolated, approximately 65% were parasitic, 31% bacterial, and 3% viral. Six organisms (giardia, campylobacter, Entamoeba histolytica, shigella, strongyloides, and salmonella species) accounted for 70% of the gastrointestinal burden.\u201d My goodness, that still leaves 2,896 other pathogens in travellers\u2019 diarrhoea, which is more than I thought existed in the Universe. Respect!<\/p>\n

Lancet\u00a0 11 May 2013\u00a0 Vol 381<\/strong>
\n1627\u00a0\u00a0\u00a0 Psychiatry is in a permanent mess, alternating between dogma and self-doubt. A century ago, it was the unconscious mind (as expounded by Middle European authority figures) which promised to explain everything: now it is going to be genomics. In the meantime, this is a bad world to be mad in. If you are labelled psychotic, you are required to conform to the latest fashion in treatment: this used to be compulsory admission under Section 17 of the Mental Health Act, but now it is increasingly a compulsory treatment order in the community. The OCTET investigators postulated that patients with a diagnosis of psychosis discharged from hospital on CTOs would have a lower rate of readmission over 12 months than those discharged on the pre-existing Section 17 leave of absence<\/a>. But that did not happen. \u201cIn well coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty.\u201d<\/p>\n

1634\u00a0\u00a0 The next trial reported<\/a> was an attempt to measure the effect of anticipatory shared decision making by people with serious mental illness. It aimed to compare the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual. \u201cThe JCP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views.\u201d This sounds like a really good idea, and a strategy that should reduce the need for compulsory admission\u2014but in this trial it didn\u2019t. The investigators seem pretty peeved: so much so that they blame the participating teams. \u201cOur findings are inconsistent with two earlier JCP studies, and show that the JCP is not significantly more effective than treatment as usual. There is evidence to suggest the JCPs were not fully implemented in all study sites, and were combined with routine clinical review meetings which did not actively incorporate patients’ preferences. The study therefore raises important questions about implementing new interventions in routine clinical practice.\u201d<\/p>\n

BMJ\u00a0 11 May 2013\u00a0 Vol 346<\/strong>
\nThe best news this week comes from Australia, and it is awesome<\/a>: quadrivalent human papillomavirus vaccination of young women in Victoria caused an 82% drop in genital warts in those offered vaccination, and a similar drop in young men of the same age group (who hadn\u2019t been vaccinated). In the women who were actually vaccinated in 2011, genital warts did not occur at all. As if to drive home the point, no significant decline was observed in older women or men, non-resident young women, or men who have sex with men. As the editorial puts it, \u201cThese are exciting times in the science of HPV and the world can confidently look forward to the virtual elimination of genital warts, recurrent laryngeal papilloma, most genital cancers, and some 60% of head and neck cancers.\u201d News doesn\u2019t often come better than that.<\/p>\n

Lordy, lordy, how some people never get it about screening. It\u2019s not that I don\u2019t recognize the thoughtfulness and intelligence of the 12 authors who wrote this paper<\/a> about the Malm\u00f6 Preventive Project in Sweden, which used data from frozen sera to show that PSA testing at 40-55 can identify a cohort of men at high risk of metastatic prostate cancer several decades later. They build up their argument carefully and acknowledge the problems of harm from overdiagnosis, only to conclude that men with low initial PSAs will need another three tests to be sure they are still at low risk. Ugh. Where is any evidence that this will reduce overdiagnosis and affect all-cause mortality? Until we have a test that tells us reliably if someone has the kind of prostate cancer that might cause death in the next few years, and we have an intervention that prevents this, we should continue to discourage all testing; or else castrate all men at the age of 60.<\/p>\n

This reminds me of an anecdote I have just read in Michael O\u2019Donnell\u2019s lovely new book, The Barefaced Doctor<\/em>. He describes a Dublin surgeon of the 1950s whose idea of patient communication was to walk down the ward calling out the name of the procedure each person should expect: \u201cIn those days elderly men with prostatic cancer were offered treatment by physical rather than hormonal castration and one morning the surgeon went on his rounds, declaiming his intentions in his usual way.
\n\u2018Laparotomy\u2026 castration\u2026appendicectomy\u2026\u2019
\n\u2018Hang on a second, sir,\u2019 said patient number two with unforgivable impertinence. \u2018This castration business? What exactly would that involve?\u2019
\nThe surgeon, perplexed by the interruption, barked a reply:
\n\u2018A simple matter, my man. We\u2019ll just remove your testicles. At your age, they\u2019re no use to you.\u2019
\n\u2018Oh, I know that, sir,\u2019 said the man. \u2018But they are kind of\u2026 dressy.\u2019\u201d<\/p>\n

Order your copy now: there is nothing else like it in this dull age<\/a>.<\/p>\n

A very useful follow-up study<\/a> of 2,411 Danish women following breast cancer treatment in 2005-6 finds that a large number experience pain and that this is least in the group who have mastectomy and lymph node biopsy only (22%), and highest in those who have breast conserving surgery combined with biopsy and chemo and radiotherapy (53%). This would imply that modern treatment modalities are actually increasing the prevalence of long-term pain. The prevalence of pain in the cohort fell between 2008 and 2012, but interestingly the traffic was not all one-way: 36% of those with pain in the earlier survey now had none, but 15% of those who had none earlier now had some.<\/p>\n

The high standard of BMJ<\/em> Clinical Reviews<\/a> continues with an exceptionally useful account of acne and its treatment. Read and learn: if you prescribe oral antibiotics, always co-prescribe a topical retinoid or benzoyl peroxide. Remember the adverse effects of many treatments and warn your patients: and also tell them to be patient, as nothing works immediately.<\/p>\n

Ann Intern Med\u00a0 7 May 2013\u00a0 Vol 158<\/strong>
\n676\u00a0\u00a0 Courtesy of the Annals, you can read the whole of a big systematic review of management strategies for asymptomatic carotid stenosis<\/a>. Golly, what a mess. \u201cStudies defined asymptomatic status heterogeneously. Participants in RCTs did not receive best available medical therapy\u2026 Future RCTs of asymptomatic carotid artery stenosis should explore whether revascularization interventions provide benefit to patients treated by best-available medical therapy.\u201d Correct me if I\u2019m wrong, but doesn\u2019t that prove that all the 47 studies analysed here were actually unethical, because they tell us nothing about how to manage asymptomatic carotid stenosis and did not give patients an adequate control intervention?<\/p>\n

Plant of the Week: Corydalis flexuosa<\/em> \u201cP\u00e8re David\u201d<\/a><\/strong><\/p>\n

Last week I told you a bit about the work of the French missionary botanist P\u00e8re Delavay, and this week it is the turn of the arguably even greater P\u00e8re Armand David<\/a>, who was ordained in 1862 and shortly afterwards sent to Beijing by the Congregation of the Mission. He set up a Museum of Natural History there, concentrating on zoology rather than botany, and his name is perhaps best remembered for P\u00e8re David\u2019s Deer, a beautiful ruminant which had nearly died out when he first discovered it in the gardens of the Emperor. He also told the West for the first time about the Giant Panda and 63 other new animal species, and 65 new species of birds: in botany, he introduced 52 new species of rhododendron alone, plus the wonderful dove tree that bears his name, and a host of smaller plants.<\/p>\n

The corydalis is a lovely tuft of finely cut brown-purple foliage with an abundance of long tubular flowers of the purest sky blue. Its main flowering season is about now, but it often carries a few a bit later. It has the habit of dying back in the summer, which can be a bit unnerving. It also has the habit of dying for good if allowed to dry out, or if exposed to too much sun. So plant it in a damp shady place and think of P\u00e8re David, a lanky man with mandarin moustaches, telling his rosary among the beasts and flowers of his new Eden.<\/p>\n","protected":false},"excerpt":{"rendered":"

JAMA\u00a0 8 May 2013\u00a0 Vol 309 1903\u00a0\u00a0\u00a0 When an implanted cardioverter defibrillator goes off inside you, you are sure to feel deeply shocked: whereas, for others, watching you drop dead […]<\/p>\n

More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":38363,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[111,447],"tags":[],"class_list":["post-26358","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-richard-lehmans-weekly-review-of-medical-journals","category-india"],"yoast_head":"\nRichard Lehman's journal review\u201413 May 2013 - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2013\/05\/13\/richard-lehmans-journal-review-13-may-2013\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Richard Lehman's journal review\u201413 May 2013 - The BMJ\" \/>\n<meta property=\"og:description\" content=\"JAMA\u00a0 8 May 2013\u00a0 Vol 309 1903\u00a0\u00a0\u00a0 When an implanted cardioverter defibrillator goes off inside you, you are sure to feel deeply shocked: whereas, for others, watching you drop dead [...]More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/bmj\/2013\/05\/13\/richard-lehmans-journal-review-13-may-2013\/\" \/>\n<meta property=\"og:site_name\" content=\"The BMJ\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bmjdotcom\/\" \/>\n<meta property=\"article:published_time\" content=\"2013-05-13T12:42:34+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2013-05-20T12:41:35+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.bmj.com\/bmj\/files\/2017\/02\/richard-lehman.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"540\" \/>\n\t<meta property=\"og:image:height\" content=\"350\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:site\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"11 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2013\\\/05\\\/13\\\/richard-lehmans-journal-review-13-may-2013\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2013\\\/05\\\/13\\\/richard-lehmans-journal-review-13-may-2013\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"Richard Lehman’s journal review\u201413 May 2013\",\"datePublished\":\"2013-05-13T12:42:34+00:00\",\"dateModified\":\"2013-05-20T12:41:35+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2013\\\/05\\\/13\\\/richard-lehmans-journal-review-13-may-2013\\\/\"},\"wordCount\":2213,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2013\\\/05\\\/13\\\/richard-lehmans-journal-review-13-may-2013\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/files\\\/2017\\\/02\\\/richard-lehman.jpg\",\"articleSection\":[\"Richard Lehman's weekly review of medical journals\",\"South Asia\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2013\\\/05\\\/13\\\/richard-lehmans-journal-review-13-may-2013\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2013\\\/05\\\/13\\\/richard-lehmans-journal-review-13-may-2013\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2013\\\/05\\\/13\\\/richard-lehmans-journal-review-13-may-2013\\\/\",\"name\":\"Richard Lehman's journal review\u201413 May 2013 - 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