JAMA   6 May 2009  Vol 301

1771    Homeless and ill in Chicago, which would you want most – a doctor or a roof over your head? This randomised trial offered chronically ill homeless people 18 months of guaranteed housing after hospital discharge, or usual care. Return visits to hospital were about a quarter fewer in the housed group. Civilisation is the building of cities, the encouragement of arts and learning from the interchange and wealth that they create, and the care of the poor. Not necessarily in that order.  http://jama.ama-assn.org/cgi/content/abstract/301/17/1771

1798    Nobody seems very sure what the human nasal sinuses are there for. From the doctor’s point of view, they exist to cause facial pain, postnasal discharge and the unnecessary prescribing of antibiotics. All this is nicely discussed (with contributions from the patient) in a case-based discussion here, with pictures of what you might find in acute rhinosinusitis if you had a nasendoscope handy. Most acute sinusitis is viral, resolves within 10 days; by this time over 50% of bacterial sinusitis will also have resolved, as far as we can tell. The commonest bacterial pathogens are Streptococcus pneumoniae and Haemophilus influenzae, followed by Moraxella catarrhalis and Staphylococcus aureus. You can only tell which from cultures obtained from endoscopic sampling, and amoxicillin remains a sensible first-line choice of antibiotic. Wait for ten days, if you can persuade the patient to do so.  http://jama.ama-assn.org/cgi/content/abstract/301/17/1798

NEJM   7 May 2009  Vol 360

1933    Coronary stents were quite a new thing when I started writing a few comments on medical journal articles ten years ago. They were all bare metal then, but trials soon appeared comparing radioactive stents (a very bad idea, causing arterial fibrosis) with stents which leech out (elute) immunosuppressant drugs such as sirolimus and paclitaxel. Coinciding with the widespread adoption of immediate percutaneous intervention for myocardial infarction, use of these drug-eluting stents shot up, and bare metal stents soon became yesterday’s technology. But was this just another triumph of marketing over evidence? It seems largely so, judging by this analysis of the Swedish Angiography and Angioplasty Registry which looks at 48,000 Swedes stented from 2003 to 2006. Overall, there was no difference in rates of death or myocardial infarction between those receiving bare metal or drug-eluting stents. Only if you take patients in the highest decile of risk can you find clear justification for using the expensive kind of stent. http://content.nejm.org/cgi/content/abstract/360/19/1933

1946    OK, I know stents are boring, but bear with me for another sentence or two. The reason everyone started using drug-eluting stents was, once again, that all-pervading enemy of patient-relevant medicine, the important-sounding surrogate end-point (ISSEP). In this latest trial comparing paclitaxel-eluting with bare metal stents following myocardial infarction, the ISSEP is called binary restenosis. Within the first 12 months, patients receiving the two kinds of stent would have noticed no difference at all. Their rates of death and stent thrombosis were identical. But those receiving the drug-eluting stents showed a lower rate of binary restenosis. Aha, that has to be good. Except that the Swedish data suggest it makes no difference to longer term outcomes in most patient groups. http://content.nejm.org/cgi/content/abstract/360/19/1946

1989    People who have tried to eat the common earth-ball fungus report that it is rather nasty. It is called Scleroderma, meaning hard-skinned. Human scleroderma, or systemic sclerosis, is definitely nasty. This review is big on mechanisms - that is its brief - and light on management. The traditional NEJM colour scheme, based on haematoxylin-eosin staining, is subtly varied with blues and greens in the illustrations. Lots of different cellular mechanisms might lead to the overproduction of collagen and other glycoproteins which characterises this distressing disease, but nobody has yet found a reliable way of switching them off.  http://content.nejm.org/cgi/content/extract/360/19/1989

Lancet   9 May 2009  Vol 373

1607    Last week I voiced the opinion that few health issues had greater global importance than theprevention of type 2 diabetes. This study of voglibose makes me wish I hadn’t put it that way. It charts the progression of 1780 Japanese “patients” from impaired glucose tolerance to type 2 diabetes. These people were not ill at all: they simply had some evidence of compromise to their beta-cell function, causing some of them to go from one arbitrary threshold up to the next. “Impaired glucose tolerance” and “type 2 diabetes” are not diseases in themselves, they are labels. They are also ISSEPs, important-sounding surrogate end-points for a process we half understand, and which unchecked can lead to patient-important end-points (PIEPs) such as myocardial infarction, visual loss, neuropathy or sepsis. This trial gets several black marks in my book: it compared one ISSEP with another; it compared an expensive new drug with placebo, instead of the best available comparator, which is metformin; it was industry-sponsored, and all the authors had taken fees from Takeda; there was a huge discontinuation rate; it was terminated too early to assess any PIEPs; the reporting of outcomes in the summary is arbitrary and sometimes inaccurate; and so on. Do α-glucosidase inhibitors have an important role to play in the prevention of the risks associated with increasing blood sugar levels? This study doesn’t give me a clue. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60222-1/abstract

1615    While I’m in drum-banging mode, I would say that few interventions are more important thanresuscitation at birth, and if babies are to get the best chance of avoiding brain damage, this needs to be done by somebody good at it as quickly as possible, i.e. by a paediatrician, in a hospital. My “conflict of interest” here is that I have fought a long battle to prevent our local obstetric unit from being downgraded to a large midwife-led unit, more than 45 minutes from any paediatric or obstetric help. This study from Bristol shows that babies who require resuscitation have an increased risk of a low IQ score at 8 years of age, regardless of their apparent health in the neonatal period. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60244-0/abstract

1632    Intracerebral haemorrhage is a gloomy topic, and I really admire those who have attempted to do randomised trials in a situation as urgent and hazardous as this. People have tried dissolving the clot with urokinase and aspirating it stereotactically; limiting its spread with activated recombinanat factor VII; or limiting its damage with neuroprotectant drugs: all to no avail in terms of patient outcomes. The aspects of management that still matter most are secondary ones such as stopping gastric bleeding (which is present in 30% of cases) and lowering blood pressure. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60371-8/abstract

BMJ   9 May 2009  Vol 338

1112    I’m all for the BMJ publishing papers that will improve clinical practice in primary care, which is why I’ve put a lot of time and effort into promoting two series in the Practice section and helping to edit one. But I find this research paper from the Netherlands (helped by the Welsh) a bit puzzling. The aim seems to be to reduce antibiotic prescribing for lower respiratory tract infection. Even the full text of the article (on the website) doesn’t contain enough evidence to satisfy me that this is a safe and laudable aim, or that there was a robust case definition for LRTI in this study. The choice of interventions in this cluster randomised trial was normal care, care guided by measurement of C-reactive protein, or care following a focussed communications skill course. The primary outcome was antibiotic prescribing. This was just over 50% in the non-testing, non-trained group and 25-30% in the other groups, including a group that used both CRP and communications skills. A good study to stimulate discussion; less good to change clinical practice, at least for an old lag like me.  http://www.bmj.com/cgi/content/full/338/may05_1/b1374

1133   The original title for the series that Anthony Harnden and I proposed to the BMJ was Commoner Than You Think? but on the whole the final title Easily Missed? is better. This is well illustrated byKawasaki disease, and here is a full clinical review written by Anthony as main author, outside our series. Kawasaki disease is not, as far as we know, commoner than most doctors think: in the UK it is so uncommon that most GPs will never see a case. But if they do, then they must try not to miss it. Treatment with immunoglobulin in the first 10 days can reduce life-threatening complications. I know I’m biased, but I can’t think you’re going to find a better guide to it than this: pore over the pictures, look out for the baby or child who is iller than her/his fever warrants; and don’t wait for desquamation of the fingers, because by then the coronary arteritis will already have happened.

P.S. Note that this condition, first described by Kawasaki, is never referred to as Kawasaki’s disease, on either side of the Atlantic. It therefore breaks the usual rules that govern the medical eponymous genitive. Like you care.  http://www.bmj.com/cgi/content/extract/338/may05_1/b1514

Ann Intern Med  5 May 2009  Vol 150

577    The optimal duration of anticoagulation following deep vein thrombosis depends on the balance between the likelihood of recurrent DVT versus the bleeding risk from continued warfarin. This Italian trial (AESOPUS) went on for 7 years but still doesn’t provide a very clear steer on whether it is useful to perform repeat ultrasonography at 3 months as a guide to continuing anticoagulation at this point. I won’t try and go into detail but there is a suggestion that outcomes may be better if you adopt the strategy of stopping warfarin at 3 months if the USS shows clear veins, but continuing it for 9-21 months if the veins still look blocked; but you will double the rate of major bleeds.  http://www.annals.org/cgi/content/abstract/150/9/577

595    A lot of us wish that prostate specific antigen testing had never been invented, because its value as a prognostic marker in advanced disease is outweighed by its Perfectly Stupid Attributes as a screening test. This study of molecular markers for risk of death from prostate cancer confirms what we were taught as medical students: prostate Ca for most men over 70 is a disease they die with rather than die from – that was true of 78.5% of the men in this study which followed up mainly moderately-differentiated tumours. The Gleason score remains a good basic indicator, but the authors here have come up with three added tissue sample tests which provide some incremental refinement. http://www.annals.org/cgi/content/abstract/150/9/595

Plant of the Week: Paeonia mlokosewitschii

Pardon me, but I can’t help praising this exquisite flower every year at the time of its appearance. Here is Reginald Farrer trying to remember how to spell its name and what it looks like, holed up in remote Western China in 1913 with a case of whisky and his trusty companion Bill Purdom:

‘P. Mlokosievitschii. – This pleasant little assortment of syllables should be practised daily, but only before dinner (unless teetotal principles of the strictest are adopted), by all who wish to talk familiarly of a sovereign among Paeonies – a rare plant, and rendered almost impregnable by its unpronounceable name. It has an ample habit and lovely dark foliage, amid and above which are borne huge flowers like strayed water-lilies of delicate saffron or citron yellow. It is in the wilds of the Caucasus that this temptation has its lair.’

The English Rock Garden 1918

In fact its wide-lobed leaves are of a light rather than a dark green, and the flowers can be of light buff mixed with pink, in what some claim to be the species – though never having been tempted as far as its lair in the wilds of the Caucasus, I wouldn’t really know. All I know is that in its commonest and best form, Mollie-the-Witch of gardens, the big papery globe-flowers are of an indescribably soft yet intense pure yellow. For a few days each year they are the most beautiful thing in the garden.

Ludwik Franciszek Mlokosiewicz was a Polish explorer, zoologist and botanist (1831-1909). His name has been mangled by botanists, but he can hold no such grouse against zoologists, who get it right in Tetrao mlokosiewiczi , the Caucasian Black Grouse. Strange how people have such difficulty spelling and pronouncing Polish names: Polish is a euphonious language with simple and consistent rules of spelling in the Roman alphabet. Yet even I couldn’t spell or pronounce my father’s Christian name till I was about 13. Mieczysław.

JAMA   13 May 2009  Vol 301

1892   A few years ago I was putting together the first book about heart failure and palliative care and decided to write the chapter about prognostic markers. There is a widespread myth that the course of heart failure is terribly difficult to predict, whereas we now have two biochemical markers – B-natriuretic peptide and co-peptin – which are more predictive than most cancer biomarkers. What I found as I was compiling this neglected masterpiece (buy it at once for your practice library) was that were in 2006 already more than a hundred different prognostic markers and scoring systems in the literature – most of them somebody’s doctoral thesis done with stored sera and/or a convenient database. I still get regular free updates on the heart failure literature through amedeo.com and still there’s a new prognostic association bruited nearly every week – here it is circulating estradiol in men with systolic heart failure. The late and much lamented Philip Poole-Wilson is among the authors. I’m sure that were he still alive he would be the first to admit that finding higher mortality in the top and bottom quintiles of serum estradiol is not going to change a great deal. “Charming but irrelevant, dear boy,” I picture him saying. Though I only met him a couple of times, I really will miss his kindness and wisdom.http://jama.ama-assn.org/cgi/content/abstract/301/18/1892

1909    Another figure who enlivened my days in the heart failure arena was John Cleland, a fervent campaigner against aspirin. I don’t know if a willow bough fell on young John’s jam-jar when he was fishing for sticklebacks by some boyhood Scottish brook, but his ardour against salicylates is remarkable. And gradually the medical world is having second thoughts on the subject. Two or three years ago, we were suggesting daily 75mg aspirin to everyone with diabetes, hypertension and/or peripheral vascular disease, and indeed to most patients with heart failure, but the evidence is remarkably thin. In this meta-analysis the effect of aspirin and or dipyridamole on cardiovascular events in PAD does not reach statistical significance. For nonfatal stroke alone, there is a protective effect.  http://jama.ama-assn.org/cgi/content/abstract/301/18/1909

NEJM  14 May 2009  Vol 2006

2066   It seems that the more you inhibit platelet aggregation, the more you prevent strokes, while leaving total cardiovascular mortality relatively unaffected. This is true of the ACTIVE A study reported here; combining aspirin with clopidogrel in atrial fibrillation achieved a 28% reduction in strokes but the rates of vascular death in the aspirin-only and the combined group was identical. Also, while the difference in fatal strokes between the groups was 23 in favour of combined treatment, the difference in fatal bleeds was 15 against. So this study doesn’t quite show the clear advantage that might inspire you to audit all your AF patients unsuitable for warfarin and urge them to take clopidogrel with their aspirin.  http://content.nejm.org/cgi/content/abstract/360/20/2066

2079    This interesting Canadian study randomised 800 babies presenting to an emergency department with bronchiolitis to receive nebulised epinephrine (adrenaline), high dose oral dexamethasone (1mg/kg), neither or both. The oral steroids and the nebulised adrenaline did nothing on their own. But combined with each other, the effect was to reduce hospital admissions. This is nicely illustrated in the cumulative admissions plot in Figure 3, but alas, when the statisticians got to work adjusting for multiple comparisons, significance was no longer achieved. Even bigger studies are needed.  http://content.nejm.org/cgi/content/abstract/360/20/2079

2108    As far as I know, nobody ever died of crumbly toenails, but apparently people have been known to die from liver failure due to oral terbinafine. This article on fungal nail disease mentions this but doesn’t quantify it, and doesn’t even come off the fence completely about liver function testing. Cost is no longer a barrier to terbinafine prescribing, but I don’t know that I could face harming a patient to treat a harmless condition, so I think I will insist on LFTs before treatment and at 6 weeks. All other treatments are a waste of time.  http://content.nejm.org/cgi/content/extract/360/20/2108

Lancet  16 May 2009  Vol 373

1673    I never grudge orthopaedic surgeons their expensive cars, because on the whole they do more obvious good to my patients than any other group of specialists. Whatever they may lack in communication skills and thinking outside the operating theatre, they make up for by fixing stuff. It took them a while to notice that immobile legs can get deep vein thrombosis, but now that realisation has dawned,thromboprophylaxis following total knee replacement has become routine. The nurses go round givingenoxaparin every 12 hours; but that may soon be a thing of the past. Each morning, as the orthopaedic surgeon throws his suit jacket into the back of the Porsche, the drug trolley will rumble round the ward laden with rivaroxaban, a fixed-dose oral factor Xa inhibitor, which proved superior to enoxaparin in this randomised trial (RECORD4).  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60734-0/abstract

1693    Much of this week’s Lancet is taken up with high-level hand-wringing about climate change. Anthropogenic climate change needs an anthropogenic answer, and since anthropes rarely change behaviour in favour of greater discomfort and lesser wealth, this needs to go beyond mere exhortation. Non-anthropogenic climate change is even scarier; a mere 15,000 years ago the place where I am typing this was the terminal moraine of a vast glacier covering northern Europe. What worries me most is the fact that all the scientific solutions seem to be proposed by grey-heads of my age or older, while the youths who ought to be coming up with the goods are too busy flying off around the world career-building.

BMJ   16 May 2009  Vol 338

1181    When the great Peter Medawar collected together his essays attacking bad science, he called the book Pluto’s Republic, after a malapropism attributed to an American lady of his acquaintance. PLUTO, the king of the underworld, also gives his name to this study – a “pragmatic multicentre randomised controlled non-inferiority trial” of the kind that Medawar might well have consigned to his infernal republic. I am inclined to be kinder, because it is difficult to study an intervention like ultraviolet B phototherapy for mild to severe psoriasis taken out into the community except in a fairly pragmatic, non-inferiority-seeking sort of way. The main point you need to establish is that patients can give themselves this therapy safely and effectively at home rather than having to come up to hospital all the time – and in this Dutch study, they could.  http://www.bmj.com/cgi/content/abstract/338/may07_2/b1542

1195   Fifteen years ago, a paper appeared from Dundee showing that levels of the then newly-discovered cardiac hormone B-natriuretic peptide were more predictive of heart failure and death following myocardial infarction than measurement of the systolic ejection fraction. This led me on a long wild-goose chase which ended when an MRC-funded pilot study showed that it was impossible to titrate individual treatment on the basis of BNP. Here a French study of elderly patients following MI confirms that BNP is a good prognostic marker: that’s the easy bit. What to do with that knowledge is still the problem – as discussed in the editorial on p.1154.  http://www.bmj.com/cgi/content/abstract/338/may06_1/b1605

1201    I draw your attention to this short paper on streptococcal perianal infection in children not (heaven forbid) because it’s by me, but as a tale of perseverance akin to Robert the Bruce and his spider, designed to inspire you to write for the BMJ. In 1996, our then registrar Sarah Pinder did a nice little awareness and case-finding study of this topic, which showed that most local GPs had never heard of it, despite the likelihood that they were probably seeing it twice a year. We urged Sarah to write it up for theBMJ at the time, but instead she got married, had babies and moved to Australia. Not long after, a new serological test appeared that for the first time made it easy to diagnose coeliac disease, and I urged Harold Hin to do a case-finding study for that, as I’ve told you oft and anon. Meanwhile I was working with less effect on BNP. All this gave me the idea for a BMJ series called “Commoner than you think”, which I proposed to them in 2002. Sorry, too ill-defined, was the reply. Then in 2006, Fiona Godlee asked if I’d like to write something for her new-look journal, and I proposed the same idea again, but now as part of a bigger series on Diagnosis at Presentation. Eventually, with the invaluable help of Anthony Harnden and Mabel Chew, this bit became “Easily Missed”. Then I finally had to track down Sarah in Australia and produce draft after draft of this little piece, known in our household as “bums”. And now, 13 years on, it appears in print, complete with a picture of a bum. If you hadn’t recognised this condition before, you will now: and if that’s the case, it was all worth it.  http://www.bmj.com/cgi/content/extract/338/may05_1/b1517

Ann Intern Med  11 May 2009  Vol 169

828   The Beginning of a New Era for the Archives and the Nation, declares the new editor, Rita Redberg, modestly placing herself by the side of Barack Obama. Those interested in American health care reform ideas will have a lot of important reading in her journal and in the other two I report on, but I shall try to keep to my general rule of not commenting directly on matters of politics. I shall simply slave on here in Egypt, making bricks without straw under the rule of Lord High Darzi until he is replaced by another Pharaoh who knew not Joseph.  http://archinte.ama-assn.org/cgi/content/extract/169/9/828

832    ALLHAT is one of those trials which will not go away, like UKPDS. Both of them could be said to have too many interventions and too many end-points, and have been the subject of much special pleading and unwarranted extrapolation. But both have unexpected and important lessons for clinical practice, confirmed by subsequent trials. In the case of UKPDS, it’s that blood pressure control is more important than tight glycaemic control, and that metformin is the most beneficial drug. In the case of ALLHAT, the message is that all drug classes for hypertension are equally good at reducing most cardiovascular end-points, and that thiazide diuretics may be the best because they prevent heart failure, and the hyperglycaemia they induce does not produce any adverse cardiovascular consequences.  http://archinte.ama-assn.org/cgi/content/abstract/169/9/832

843    Various medical conditions have from time to time been known as Syndrome X, indicating general mystification, and none is more mystifying than cardiac chest pain on exertion in women with normal coronary arteries. The Women’s Ischaemia Syndrome Evaluation Study (WISE) followed up women with ischaemic symptoms but normal coronary arteries for a mean of 5.2 years and compared them with a cohort of asymptomatic women from the St James Women Take Heart Study. The 540  “WISE women” (as the study describes them) did markedly worse than the Take Hearters. In women with 4 or more cardiac risk actors, their annual event rate exceeded 25% while it was 6.5% in the asymptomatic.  http://archinte.ama-assn.org/cgi/content/abstract/169/9/843

858    Pre-scientific medicine developed some pretty effective rituals for pain relief, the most impressive and persistent being acupuncture. This study, like many others, shows that it works well for a lot of people, whether you follow the traditional points or do it at random. To perform acupuncture, you just need a set of sterile long thin needles and an impressive manner. Exhibit charts of ancient Chinese pricks on the walls of your room. Enquire about the exact nature and location of the chronic low back pain and perform a slow and meticulous examination. It may help to insist that the patient comes in a loin cloth. After a period of serious contemplation, proceed to introduce the needles wherever you like. Make sure you charge a high fee. This increases your reputation and allows you to wear finer robes.   http://archinte.ama-assn.org/cgi/content/abstract/169/9/858

Plant of the Week: Iris “Black Swan”

All bearded irises are lovely, and with most the scent seems to complement the colour: a rich fruit salad smell from the pink and brown ones, something more exotic from the blues, and chocolate and liquorice from this almost black one. Definitely a flower to turn heads, especially when planted where the sun can shine through it, producing an effect like very dark stained glass.

I imagine that all the many iris varieties with “black” in their name are very similar. Split them regularly and give bits to admirers.