{"id":28536,"date":"2013-08-27T10:35:16","date_gmt":"2013-08-27T09:35:16","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=28536"},"modified":"2013-08-27T10:35:16","modified_gmt":"2013-08-27T09:35:16","slug":"richard-lehmans-journal-review-27-august-2013","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2013\/08\/27\/richard-lehmans-journal-review-27-august-2013\/","title":{"rendered":"Richard Lehman’s journal review\u201427 August 2013"},"content":{"rendered":"

\"RichardNEJM\u00a0 22 Aug 2013\u00a0 Vol 369<\/strong>
\n699\u00a0\u00a0\u00a0 Vedolizumab. What a name for an important new drug. Just remember the vedo bit and the fact that it\u2019s a monoclonal antibody, and you might be able to recall the full name. Vedo is the new kid on the block for inflammatory bowel disease. \u201cHi new kid,\u201d say the lymphocytes in the bowel wall, \u201cwhat\u2019s your name?\u201d \u201cMy name is Vedo, and my aim is to stop you causing mischief. Bow down before me and obey.\u201d \u201cHah, hah,\u201d say the lymphocytes, and trash Vedo in 53% of cases. But in the other 47% of cases,<\/a> Vedo wins. This is success in ulcerative colitis, because with placebo, only 25% of patients who relapsed after other treatments go into remission and most don\u2019t maintain it, whereas vedolizumab manages to keep over 40% of the original 47% in remission.
\n<\/p>\n

711\u00a0\u00a0 But response rates to vedolizumab<\/a> are much poorer in treatment resistant Crohn\u2019s disease. There\u2019s an editorial to explain what it does and why this might be so. Maybe you need to remember Vedo, maybe you don\u2019t.<\/p>\n

722\u00a0\u00a0 GlaxoSmithKline pits its new renal cancer drug, pazopanib, against the established Pfizer drug, sunitinib. Pazopanib wins, by causing fewer adverse effects. To confirm this, we need the full clinical study reports, because so far they have only been analysed by the sponsor, GSK. But for its design, this trial<\/a> deserves congratulations: it was well powered, it measured patient-important end-points including fatigue, and it compared the new drug with the best existing similar treatment. Since GSK has promised to release full data from all its trials, this would be a good one to look at: if its conclusions are confirmed independently, then GSK can market its product with pride.<\/p>\n

Ann Intern Med\u00a0 20 Aug 2013\u00a0 Vol 159<\/strong>
\n233\u00a0\u00a0 Following Ray Moynihan et al\u2019s measured argument in the BMJ<\/em> against labelling 11% of adults as having \u201cchronic kidney disease,\u201d there have been lots of responses from single interest people to the effect that this is so that we can target them for special preventive treatment, including tighter control of blood pressure. This study of US Veterans with CKD<\/a> introduces some observational evidence into the debate. Lowering diastolic BP in these people below 70 is associated with higher mortality, irrespective of the systolic pressure. The best outcomes were seen with diastolics between 70 and 89, and systolics between 130 and 159 Hg. Note that last figure. Male \u201cpatients with CKD\u201d\u2014mostly healthy asymptomatic people\u2014are quite OK to run a systolic BP up to 159, and not OK to run a diastolic below 70. These figures bear no relation to any targets set by tunnel-vision committees of specialists and CKD \u201cchampions,\u201d and apply equally to those with albuminuria and those without.<\/p>\n

JAMA\u00a0 21 Aug 2013\u00a0 Vol 310<\/strong>
\nThe order in which I place the journals in these reviews was never meant to be a reflection of merit, but simply reflected the order in which I read them in paper copy back in 1998 (see end section). The reason JAMA<\/em> has recently appeared lower in the order these days is because I don\u2019t like to start every review with a moan.<\/p>\n

699\u00a0\u00a0 Moan! A structured hypertension management programme by Kaiser Permanente in the USA achieves better BP control than usual care<\/a>. Strange indeed had it been otherwise. There\u2019s not much for NHS doctors to learn from here: keep collecting the QOF BP points.<\/p>\n

722\u00a0\u00a0 A trial<\/a> to determine whether lateral wedge insoles reduce pain in patients with medial knee osteoarthritis. They do not. This is useful knowledge for those who might be tempted down this route. No moan.<\/p>\n

731\u00a0\u00a0 The ever valuable rational clinical examination series asks \u201cDoes This Patient Have Obstructive Sleep Apnoea?<\/a>\u201d No moan here either, because this patient does indeed have it, and since starting CPAP he finds it much easier to stay awake while writing these reviews. To him, the diagnosis seemed perfectly obvious for years from the excellent descriptions of his nocturnal noise making offered by his spouse, his unfortunate gain in neck circumference, his mildly elevated blood pressure and his inability to stay awake in afternoon meetings. It was merely a matter of getting round to having a sleep study. And like most people with OSA, I wish I\u2019d done it ages ago. An Australian study a couple of years ago dispensed with the sleep studies and just gave out the CPAP machines on the basis of the history, the Epworth score, BMI, neck measurement, and the Mallampati pharyngeal airway score, which is basically how much of the uvula you can see. So you can diagnose yourself in most cases, though this systematic review would have you believe otherwise. That\u2019s the trouble with systematic reviews of the diagnostic literature: they\u2019re hard work, and you end up not believing them, because every study seems to have a different population and a different set of measurement criteria. Forget sleep studies and cut to the CPAP, say I.<\/p>\n

BMJ\u00a0 24 Aug 2013\u00a0 Vol 347<\/strong>
\nThe management of depressed patients in UK primary care is a mess. It simply cannot be otherwise, given the constraints of the ten minute consultation and the interminable waiting times for psychological therapy. Even the most reluctant GPs feel forced to start patients on SSRI antidepressants, which most people then find difficult to discontinue. The investigators of the CADET trial<\/a> claim to have found a better way, and suggest that it could be implemented across the UK. They trawled through GP records to find patients coded with depression. They ultimately managed to recruit 11% of those found. The intervention consisted of antidepressants and\/or a simplified form of CBT, with adherence supervised by \u201ccare managers\u201d in 6-12 contacts per patient. At four months, mean depression score was 11.1 (standard deviation 7.3) for the collaborative care group and 12.7 (6.8) for the usual care group. There is no cost analysis. Ready for roll-out? I don\u2019t think so. Just give us the CBT next week, and we will be able to help our patients.<\/p>\n

Here\u2019s a nice big cohort study from Dijon<\/a> which really cuts the mustard. It looks at the behavioural factors associated with disability in old age. Alcohol? Those who stop drinking fare worst. Encore de bon vin! Smoking? A surprisingly small effect. Pas de cigarettes! Diet? Yes, those who fail to get their fruit and vegetables do quite a lot worse. Encore de salade! Inactivity? Here there\u2019s a really big effect, confounded by reverse causation. Il faut faire la promenade. It\u2019s all there to be mulled over on Table 2.<\/p>\n

Anything written by Rudolf Klein is worth reading, and his essay on the NHS in the age of anxiety<\/a> certainly is. The universally free and comprehensive NHS was set up when Britain was in ruins and bankrupt: food was rationed, but everybody could get free medical care, with specs and teeth thrown in. Now all the political parties collude in the myth that in 2013 we are too poor a country to provide adequate healthcare for everybody. The Lansley \u201creforms\u201d have lain the whole system open for cherry-picking by the private sector. Why aren\u2019t Her Majesty\u2019s Opposition screaming? Klein\u2019s last paragraph is calmly brilliant:<\/p>\n

\u201cThe age of austerity is, of course, itself the product of rhetoric. It is the rhetoric of a model that sees salvation in balanced budgets and reduced public borrowing and results in the reality of economic stagnation and cuts in public spending. This hairshirt approach has been challenged by many, Nobel prize winning economists among them. And the best hope for the NHS is that the challenge will succeed before too many irreversible lesser evils have been found acceptable.\u201d<\/p>\n

Great clinical pieces abound, as usual in the BMJ<\/em> these days. Read a good review of Tourette\u2019s<\/a>, spot imported malaria with the help of Merlin Willcox<\/a>, and be reminded that type 2 diabetics with totally burnt-out beta-cells can get ketoacidotic<\/a>.<\/p>\n

Lancet\u00a0 24 Aug 2013\u00a0 Vol 382<\/strong>
\n694\u00a0\u00a0 The 1665 motto of the Royal Society enjoins us not to take anyone\u2019s word for things but to look at the evidence. The trouble nowadays is that you do have to take people\u2019s word for things, because you can\u2019t possibly do the analyses yourself. Three French authors collect all the limited evidence<\/a> we have about the transmissibility of the new betacoronavirus, MERS-CoV<\/a>, and put it through their mathematical software. They arrive at an R0 between 0.6 and 0.65. Aha, I hear you say, is that good or is it bad? Well, let me tell you that this morning I discovered what an R0 is, or at least what it means. If it is less than 1, the world is safe from pandemic spread: it means that the infection will fizzle out, like SARS, which had an R0 of 0.8. If the R0 gets to 1.5 or above, be scared, wear protective clothing, and start producing vaccines as fast as you can.<\/p>\n

Fifteen Years of These Reviews<\/strong><\/p>\n

By 1998, I had been at Hightown Surgery in Banbury for 19 years. Our patient list had grown fourfold, and we had become a training practice and had a nice library in our common room. We subscribed to the main generalist medical journals for the sake of ourselves and our trainees, but none of us seemed to read them much. So I suggested that we each took one home each week and wrote down some comments on the papers of general interest.<\/p>\n

By the end of August that year it became clear that I would be the only contributor to this process. Either we would drop the idea or I would carry on doing it on my own.<\/p>\n

The fifteen year mark has now been reached, and I can look back at some wonderful friendships and opportunities as a result of carrying on. I still enjoy the writing, but above all I am kept going by the feedback I get from time to time.<\/p>\n

The down side is that I have not had a free weekend for fifteen years, during which I have managed to keep the process unbroken. Now I feel like a short break, so there will be no reviews for the next fortnight.<\/p>\n

After that, another fifteen year cycle begins. Perhaps.<\/p>\n","protected":false},"excerpt":{"rendered":"

NEJM\u00a0 22 Aug 2013\u00a0 Vol 369 699\u00a0\u00a0\u00a0 Vedolizumab. What a name for an important new drug. Just remember the vedo bit and the fact that it\u2019s a monoclonal antibody, and […]<\/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],"tags":[],"class_list":["post-28536","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-richard-lehmans-weekly-review-of-medical-journals"],"yoast_head":"\nRichard Lehman's journal review\u201427 August 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\/08\/27\/richard-lehmans-journal-review-27-august-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\u201427 August 2013 - The BMJ\" \/>\n<meta property=\"og:description\" content=\"NEJM\u00a0 22 Aug 2013\u00a0 Vol 369 699\u00a0\u00a0\u00a0 Vedolizumab. 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What a name for an important new drug. 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