Richard Lehman’s journal blog
Richard Lehman is an Oxfordshire GP who, some time ago, started writing a weekly review of JAMA, the Lancet, the New England Journal of Medicine, and the BMJ for a few friends; the circulation then grew to the primary care department at Oxford University and beyond.
“Cheer up at once,” is Richard’s advice this week. Reasons to be cheerful include the fact that people may well eat fish in heaven (and possibly ceps). Other good news: flu vaccination reduces lower respiratory tract infections and pneumonia in elderly people. Read on...
J A M A 18 Oct 2006 Vol 296
Coronary artery bypass graftinghas become the commonest major surgical procedure in the developed world. But since it tends to be needed most in people who are old, have smoked, got fat, and/or become diabetic, there is a sizeable risk of post-operative pulmonary complications. A team from Utrecht sensibly wondered if these might be reduced by training the least fit to breathe properly by the use of preoperative intensive inspiratory muscle training. They demonstrate that this intervention cuts post-operative pneumonia by more than half, and the average hospital stay by a day. Maybe some hospital trusts will decide it is cost-effective, unless they have already sacked all their respiratory physiotherapists.
You can’t do medicine without poisoning people, though you can try to reduce the risk of adverse drug events(ADEs), or adverse drug reactions (ADRs) as we tend to call them over here. This survey looks at 21 298 ADEs presenting to US emergency departments and gives an excellent general overview of the classes of drug and the kinds of reaction. Insulin and warfarin provide the biggest problems, as you’d expect.
Like childhood cancer, dilated cardiomyopathy in childrenstrikes randomly, and a proportion of it may be caused by viruses. A predisposing condition can only be identified in a third of cases, and of these, half have myocarditis. Overall, 31% die within a year (or, rarely, get transplanted); at five years, the figure is 46%. (Commercial plug: for a discussion of the issues around the care of children and young people dying from heart failure, see the excellent chapter by Hayley Pryse-Hawkins in Heart Failure and Palliative Care eds. Johnson and Lehman, Radcliffe 2006).
Should we eat fish?You betcha. Especially with large quantities of dairy-based sauces, in case people suspect you of being a healthfreak.Dover sole withbéarnaise; skate in black butter; turbot with cream and sorrel; trout with buttered cèpes; Matjesfilets of salted raw herring with heaps of sour cream: the list is as wide as the ocean. Warning: may contain traces of methylmercury. This rather dour clinical review(“evaluating the risks and the benefits”) recommends a modest weekly intake of fish to reduce coronary events by 36% and “total mortality” by 17%. So people eat fish in heaven! I knew it!
N E J M 19 Oct 2006 Vol 355
I first became aware of dehydroepiandrosteronesome years ago when a patient with Addison’s disease asked if I could prescribe it to help her general well-being and libido. Not wishing to deny her these benefits, I read up about it and discovered that it is the most abundant hormone produced by the adrenal cortex but nobody is sure what it is for. And no, it is not prescribable in the UK, though you can buy it from innumerable websites (5 million Google hits) selling the stuff as the elixir of youth. In this trial old people were randomised to DHEA or placebo for two years; some of the men were also randomised to testosterone. Did they leap and rut like young deer? Not a bit of it. DHEA stands for Dreadfully Hyped and Entirely Actionless.
You’ll remember that a trial called SPACE a couple of weeks ago showed that carotid stentingwas probably inferior to endarterectomyin patients with moderate to severe carotid stenosis. In this French trial (EVA-3S) the stented group had nearly double the rate of death or further stroke compared with the endarterectomy group. So although the previous editorial was probably right in saying that SPACE is not the final frontier (in the carotid stenting debate), EVA-3S probably is.
Slowly, oh how slowly, we are piecing together what actually makes children wheeze (or “causes childhood asthma” if you believe in that diagnostic label). One of the groups working on the question is the Oslo Research Group for Asthma and Allergy in Childhood, made to form the acronym ORAACLE by gratuitously adding the Lung and the Environment. This Sibyl of the North declares that babies born with reduced lung function are more likely to have asthma at the age of ten.
Chronic prostatitisis a pain in the crotch. There is no diagnostic test except the two—or three—glass test, illustrated in Figure one, which involves massaging the prostate per rectum for a minute. If the urine grows a germ, at least you have something to treat. Most often it doesn’t, in which case nobody has a clue. We generally try quinolone antibiotics for a while, and some have even gone as far as injecting antibiotics into the prostate, with possible benefit, though I can’t see patients queuing up. Alpha-blockers have no proven effect. Some of my patients have been recommended by specialists to ejaculate at least once a day, but this review fails to mention this. Perhaps it was only said to cheer them up.
B M J 21 Oct 2006 Vol 333
This week’s BMJ is devoted to “Health in the Middle East” and is a curious hotch-potch of conflicting themes which will satisfy nobody, reflecting the region itself. The “Editor’s choice” leading article more or less says so. I think the key question for doctors is whether we can hope that the ethos of medicine—which does not recognise distinctions of race and religion, and should not recognise distinctions of wealth—can help to bring about political and social reform. But one of the painful lessons of growing old is that however much you may try to make the world a better place, somebody else will always be busy screwing it up. My generation of Western politicians has doomed the Middle East to bitterness and violence for at least the lifetime of my children.
Blake for the Week
… On the Euphrates Satan stood
And over Asia poured his pride.
He wither’d up sweet Zion’s hill
From every Nation of the Earth;
He wither’d up Jerusalem’s gates
And in a dark land gave her birth.
He wither’d up the Human Form
By laws of sacrifice for sin,
Till it became a Mortal Worm,
But O! translucent all within.
from the Preface to Book II of Jerusalem , written and etched 1804-1820
Lancet 21 Oct 2006 Vol 368
“Health is now the most important foreign policy issue of our time” says Richard Horton on the front cover of this week’s Lancet, quoting from his own editorial. You need a pretty broad definition of “health” to make this stick in relation to Iraq (see the casualty figures). But I can agree that a healthy foreign policy might start with not invading other countries on false pretexts, destroying their infrastructure and triggering uncontrollable civil wars.
Otitis mediaremains the most frequent reason for giving antibiotics to children, even though we are told that they make little difference. This meticulous and clearly written meta-analysisusing individual patient data gives us the figures we need. The numbers needed to treat (NNTs) are: