{"id":36807,"date":"2016-06-06T11:35:02","date_gmt":"2016-06-06T10:35:02","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmj\/?p=36807"},"modified":"2016-06-06T11:36:09","modified_gmt":"2016-06-06T10:36:09","slug":"richard-lehmans-journal-reviews-6-june-2016","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmj\/2016\/06\/06\/richard-lehmans-journal-reviews-6-june-2016\/","title":{"rendered":"Richard Lehman’s journal reviews\u20146 June 2016"},"content":{"rendered":"

\"richard_lehman\"NEJM 2 Jun 2016 Vol 374<\/strong>
\nGerms, catheters and hospitals<\/span>
\n2111 Anyone who has an indwelling urinary catheter will get bacteriuria, sooner or later. I was taught this as a medical student, as a medical HO and urology SHO, and observed it through 35 years as a GP. This article begins by stating<\/a> that up to 69% of catheter-associated UTIs are considered to be avoidable, provided that recommended infection-prevention practices are implemented. It\u2019s the kind of claim that begs questions: is asymptomatic colonisation the same as \u201cUTI\u201d? Is this a statement about hospitals, or the community, or nursing homes, or all three? Still, it\u2019s hard to argue against taking precautions against introducing organisms into the urinary tract, especially in already sick patients in hospital. And a prevention package may work, according to this carefully reported before-and-after study. Data were obtained from 926 units in 603 American hospitals as they introduced a program designed to reduce catheter infection. Infections went down on the wards but not on intensive care units.<\/p>\n

Embedding or embalming practice-based research?<\/span>
\n2152 Retirement from clinical practice is a great opportunity for big thinking. Why isn\u2019t every clinical encounter a learning opportunity for the patient, the health professional and the system, we grandly ask. \u201cBecause we don\u2019t have the bloody time,\u201d comes the answer from ten thousand people who still do the job. This is a strong theme in a paper about Integrating Randomized Comparative Effectiveness Research with Patient Care<\/a>. The barriers put in the way of obviously beneficial embedded research in the UK make for squirm-inducing reading:\u00a0\u201cThe overarching [NHS] governance review took 2 years from original application to approval, followed by local approvals (which took a further year in England, but only 2 months in Scotland). Several regions demanded local modifications of the trials, including localised consent forms and, because of prescribing guidelines, mandatory switching from atorvastatin to simvastatin in Retropro 3 months after trial entry. Several [general practitioners] were also warned that Retropro would adversely affect their statin performance targets (most regions restricted atorvastatin prescribing). Review by the ethics committee resulted in a considerable lengthening of the informed consent form.\u201d No wonder that out of 270 practices that expressed an interest in this trial, 17 ended up recruiting patients.<\/p>\n

Dissing RCTs is not big or clever<\/span>
\n2175 Conducted rigorously in a representative population with the right comparator, a double-blinded randomized controlled trial is the best method yet devised to test a clinical intervention. Here\u2019s an article which traces the history of the RCT<\/a> and points out all the pitfalls of conducting and interpreting them in real life. If you are familiar with the subject, you won\u2019t learn much that\u2019s new, but you will get the feeling that now and then the authors are hinting that they aren\u2019t really worth the bother, and that lesser standards of evidence will do for most purposes. For a second week in succession I need to mention Vinay Prasad<\/a>, who has written a fiery critique of this article and this attitude.<\/p>\n

That most RCTs are cumbersome, expensive, and deliberately designed to sell products rather than honestly test a hypothesis is no criticism of the RCT as such. But it is a huge criticism of a system which delegates their conduct to people with a financial or career interest in their results, and their publication to journals which can derive a tidy income from selling reprints of them. Somehow I don\u2019t expect this is a criticism which will appear in the NEJM<\/em>.<\/p>\n

Ann Intern Med Jun 2016 Vol 164<\/strong>
\nYou don\u2019t fatten a pig by weighing it<\/span>
\nOL It\u2019s hard to argue with the principle that you can\u2019t demonstrate improvement in a system unless you have some way of measuring it. Famously they measured increases in productivity at the Hawthorne Works in 1925 after introducing changes in lighting. It took another 30 years for Landsberger to realize that the improvements in productivity were nothing to do with lighting levels but lots to do with the workers knowing that they were being observed. Now the \u201cHawthorne Effect\u201d is so embedded in urban myth that many managers assume that if they introduce highly intrusive methods of quality measurement, they are bound to drive up quality. So what happened after Medicare introduced public reporting of hospital death rates for acute myocardial infarction, heart failure, and pneumonia in 2008<\/a>? Oddly\u2014and perhaps coincidentally\u2014this step (called Hospital Compare) was associated with a slowing in the decline of mortality from these conditions. Let me repeat that in the exact words of the investigators: \u201cChanges in mortality trends suggest that reporting in Hospital Compare was associated with a slowing, rather than an improvement, in the ongoing decline in mortality among Medicare patients.\u201d This is counter-intuitive, but by no means unique. I think there needs to be a term for the obverse of the Hawthorne Effect. I\u2019d suggest we call it the \u201cQOF Effect,\u201d after the UK\u2019s Quality & Outcomes Framework for primary care, where the harrying of professionals to comply with a list of badly judged quality measures resulted in gaming, demoralisation, and a drop in real quality of practice. Having had my rant, however, I would advise against placing too much reliance on this single before-and-after study.<\/p>\n

Lancet 4 Jun 2016 Vol 387<\/strong>
\nWHO on Earth<\/span>
\n2276 Some years ago, I took a self-denying ordinance not to mention Richard Horton\u2019s Offline<\/em> column. But I cannot resist quoting these sentences<\/a>: \u201cYou will never find a World Health Organization official prepared to state on the record that a country is betraying its people by ignoring their wellbeing. The politesse of international health is dishonest, duplicitous, contemptible, venal, and, sometimes, even criminal.\u201d Bravo. In theory, the WHO should be the most valuable institution on the planet. Instead, it is a glaring example of how cynicism, political undermining, and internal sclerosis can destroy a great endeavour. But the only way forward is to rebuild, not to despair.<\/p>\n

Scores of belief systems<\/span>
\n2302 Medical research is coming to resemble particle physics. The fountains of knowledge are arcane and we have to take a great deal on trust because we cannot possibly replicate or analyse the findings ourselves. This applies across a wide range of areas such as population epidemiology, genomics, observational studies, outcomes research, and scoring systems based on complex data. We rely on experts to tell us what they see. If they tell us that some squiggle on a screen shows the generation of an electron antineutrino via an intermediate heavy W boson, we just have to murmur \u201camazing\u201d in a knowing way. There\u2019s no means of checking, short of spending a few years learning the subject and using the equipment. In this paper we are told that<\/a> \u201cThe ABC-bleeding score, using age, history of bleeding, and three biomarkers (haemoglobin, cTn-hs, and GDF-15 or cystatin C\/CKD-EPI) was internally and externally validated and calibrated in large cohorts of patients with atrial fibrillation receiving anticoagulation therapy. The ABC-bleeding score performed better than HAS-BLED and ORBIT scores and should be useful as decision support on anticoagulation treatment in patients with atrial fibrillation.\u201d OK boss, you know best. But have you actually found out how well this predicts bleeds in little old ladies with AF? Or how much it would cost combined with every prescription for a direct oral anticoagulant?<\/p>\n

Predicting tuberculosis<\/span>
\n2312 \u201cA third of the population worldwide is infected with Mycobacterium tuberculosis<\/em>, but less than 10% of these individuals will progress to have active tuberculosis disease during their lifetime; most individuals will remain healthy.\u201d Finding a way of identifying the people at highest risk and treating them prophylactically would be a fantastic step forward for the world. \u201cA 16 gene signature of risk was identified<\/a>. The signature predicted tuberculosis progression with a sensitivity of 66\u20221% (95% CI 63\u20222\u201368\u20229) and a specificity of 80\u20226% (79\u20222\u201382\u20220) in the 12 months preceding tuberculosis diagnosis.\u201d I really hope this is a breakthrough, and that clinical treatment programmes will become possible and affordable. Tuberculosis is a fascinating and tragic enigma throughout human history, wonderfully explored in The White Death<\/em> by Thomas Dormandy (1998; out of print). Over the last two hundred years, irreplaceable literary genius seems to have been a grave prognostic marker. Imagine if John Keats, Emily Bronte, Anton Chekhov, and George Orwell had not died prematurely. I hate TB.<\/p>\n

UK general practice: worked to death<\/span>
\n2323 For decades, British GPs have been fed data about their consultation rates, but when Richard Hobbs and his co-authors came to measure changes in GP workload over recent years, he found the data were poor and outdated. Here is an analysis<\/a> based on very dependable figures from the Clinical Practice Research Datalink (CPRD). In terms of recorded face-to-face consultations, GP workload increased by 16% over the six years ending 2014. I don\u2019t want to labour the point. \u201cThese results suggest that English primary care as currently delivered could be reaching saturation point. Notably, our data only explore direct clinical workload and not indirect activities and professional duties, which have probably also increased.\u201d People can work very hard indeed if their efforts are highly valued and there is the promise of amelioration. But the government has gone out of its way to remove any sense of value and hope from general practice. Ironically, this article is open access thanks to funding by Department of Health UK. The money should have come from the Department of Health Australia, the chief beneficiary of despair amongst British GPs.<\/p>\n

TheBMJ 4 Jun 2016 Vol 353<\/strong>
\nIn your coding dreams<\/span>
\nThe first editorial in this week\u2019s print issue of\u00a0The BMJ<\/em> has the subtitle \u201cClinicians need to embrace new coding technology with enthusiasm.<\/a>\u201d Believe me, there is nothing less likely in the entire universe.<\/p>\n

A senior moment<\/span>
\nThese weekend rantings of mine are now given the status of \u201cResearch Update\u201d by the print issue of\u00a0The BMJ<\/em>, and because of a Monday holiday, last week\u2019s were rushed into print without checking. Finding two articles on renal replacement therapy for ICU patients from different European countries, I struggled to compose a sentence in schoolboy German rather than to read the actual trial from Germany. Alas, my mistake is now embedded in print for all to see throughout eternity. The German trial contradicted rather than confirmed the French one, as many a baffled nephrologist tweeted to inform me. I shall abjure nephrology henceforth forever, and perhaps even check on what I write in the future.<\/p>\n

Telebothering<\/span>
\nWhen a Roman emperor celebrated his triumph at Rome after a great victory, he would be accompanied by a slave who whispered from time to time \u201cRemember that you are but a mortal, great Caesar.\u201d Legend does not recount what happened to these slaves afterwards. Here is a trial<\/a> in which telephone callers reminded people with raised cardiovascular risk that they were mortal and should do something about it. The fate of these callers is similarly unknown. We do not know if they were thrown into vats of boiling oil. And like Roman emperors, the recipients of this advice did not display much measurable benefit. Or, to give this trial its due, \u201cThis evidence based telehealth approach [sic] was associated with small clinical benefits for a minority of people with high cardiovascular risk, and there was no overall improvement in average risk.\u201d But, \u201conly 16% of those sent information about the trial expressed interest in participating, and only a third of intervention participants received the full course of intended telephone encounters.\u201d Beware: I have a special vat of boiling oil ready for anyone who mentions the word \u201ctelehealth.\u201d<\/p>\n

Is migraine a CV risk factor?<\/span>
\nMigraine in women has been studied more closely than migraine in men, according to a wonderfully sensible commentary accompanying an analysis of migraine and cardiovascular risk<\/a> from the Nurses\u2019 Health Study. Like several previous observational studies, this shows a small increase in absolute risk of CV events in women who reported migraine. This is not confined to stroke. So what\u2019s to be done? The editorial concludes that “At present, migraine is probably best thought of as a situation in which the medical urge to ‘do something’ (beyond currently recommended assessments for cardiac risk and advocating a healthy lifestyle) should be resisted, especially when migraine is a patient\u2019s sole risk factor. As Will Durant has observed, ‘One of the lessons of history is that nothing is often a good thing to do.’\u201d<\/p>\n

Plant of the Week: Rosa<\/em> \u201cLady Hillingdon, Climbing\u201d<\/a><\/strong><\/p>\n

I know nothing of the original Lady Hillingdon, or if she was a climber in real life. The enchanting rose that bears her name flowers a deep yellow-orange and has handsome purpled leaves. If I were Lord Hillingdon and she entered my drawing room, I would propose marriage immediately, be she the poorest blacksmith\u2019s daughter.<\/p>\n

This really is a most beautiful plant at a time when there is no shortage of beauty. Beguilingly fragrant too, at a time when there is no shortage of fragrance. And reasonably easy to please too, though we planted our previous one in dry shade and she sulked and died. Perhaps she needs a rich sunny home with attentive servants.<\/p>\n","protected":false},"excerpt":{"rendered":"

NEJM 2 Jun 2016 Vol 374 Germs, catheters and hospitals 2111 Anyone who has an indwelling urinary catheter will get bacteriuria, sooner or later. I was taught this as a medical student, as a medical HO and urology SHO, and observed it through 35 years as a GP. This article begins by stating that up […]<\/p>\n

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