{"id":87,"date":"2007-01-15T15:31:01","date_gmt":"2007-01-15T14:31:01","guid":{"rendered":"http:\/\/resource.bmj.com\/bmj\/2007\/01\/15\/ann-intern-med-8-jan-2007\/"},"modified":"2007-01-15T15:31:01","modified_gmt":"2007-01-15T14:31:01","slug":"ann-intern-med-8-jan-2007","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2007\/01\/15\/ann-intern-med-8-jan-2007\/","title":{"rendered":"Ann Intern Med 8 Jan 2007"},"content":{"rendered":"<p>A <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/10\">systematic review<\/a> attempts to look at all studies which compare <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/10\">generalist <\/a>with <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/10\">specialist care<\/a>. This is doomed for various reasons discussed in the accompanying <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/8\">editorial<\/a>, not least because most of the studies are observational, very few are randomised, it is generally impossible to adjust for case-mix, and it is very difficult to assess publication bias. <!--more-->Also, this is definitely the sort of review where pears are discussed alongside sea-going mammals. The specialists, of course, almost always get the better press. But do they deserve it? <\/p>\n<p>Here\u2019s a <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/21\">systematic review<\/a> which deals, thank goodness, entirely with randomised controlled trials, and attempts to find out whether supplements of <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/21\">homocysteine-lowering vitamins<\/a> improve <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/21\">cognitive function<\/a>. As readers will be aware, the evidence is disappointing \u2013 there is nothing to suggest that B<sub>6<\/sub>, B<sub>12<\/sub> or folic acid given to people with normal or impaired cognitive function helps to improve it. <\/p>\n<p>The next <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/31\">systematic review<\/a> establishes that your <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/31\">C-reactive protein<\/a> is likely to fall if you lose weight, in case you\u2019re interested.<\/p>\n<p>If someone is <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/40\">dying<\/a>, who tends to look <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/40\">after them most<\/a>? Goodness me, it\u2019s their families: who would have thought it? This <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/40\">study <\/a>even goes so far as to suggest that families often don\u2019t get all the support they need, and that we ought to take that into account in end-of-life care.<\/p>\n<p>Another bit of evidence in favour of <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/53\">influenza vaccine<\/a>, consistent with other studies: it is associated with a reduction in <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/53\">mortality <\/a>in adults hospitalised with <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/53\">community-acquired pneumonia<\/a>.<\/p>\n<p>68    Another contribution to the debate about how patients enrolled in randomised controlled trials differ from real-life patients. We know that in most settings, such as here in the <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/68\">GRACE study<\/a> of <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/68\">myocardial infarction<\/a>, the sickest patients tend to have <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/68\">exclusion criteria<\/a> and so <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/68\">fare worst<\/a>. Next come the patients who are <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/68\">eligible but not enrolled<\/a>. In theory these should fare exactly the same as the placebo group of enrolled patients, but in fact they fared significantly worse (OR for mortality 1.6). So there was some factor in favour of enrolled trial patients which these investigators couldn\u2019t identify.<\/p>\n<p>Oddly enough, the first time I heard about <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/74\">thrombolysis <\/a>was when as a student I heard it mentioned as an experimental treatment for massive pulmonary embolism. More than 30 years later, this <a href=\"http:\/\/www.annals.org\/cgi\/content\/full\/146\/1\/74\">paper <\/a>shows that the question of its effectiveness still hasn\u2019t been settled, at least in the context of submassive PE.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A systematic review attempts to look at all studies which compare generalist with specialist care. This is doomed for various reasons discussed in the accompanying editorial, not least because most [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2007\/01\/15\/ann-intern-med-8-jan-2007\/\">More&#8230;<\/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-87","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-richard-lehmans-weekly-review-of-medical-journals"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Ann Intern Med 8 Jan 2007 - 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\/2007\/01\/15\/ann-intern-med-8-jan-2007\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Ann Intern Med 8 Jan 2007 - The BMJ\" \/>\n<meta property=\"og:description\" content=\"A systematic review attempts to look at all studies which compare generalist with specialist care. 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