Clinical practice and research blog
Richard Lehman's Journal Blog 24th May
JAMA 19 May 2010 Vol 303
1921 This week's JAMA is devoted to mental health issues, as we now call them. When I began my medical career, we would have called these psychiatric problems. But now we have moved away from the model of the fretful psychiatrist taking on the personal problems of a multitude of individuals to a model of team care where the main aim seems to be to prevent any personal bonding between patients and professionals. This, plus the unwieldy nature of the interventions, the huge time delays and the constant changes of service provision, all mean that patients turn to GPs for the timely personal involvement that they really need. They may make our hearts sink, but that is the nature of the job. Anyway, that's enough from me: I am retiring and saying a genuinely fond farewell to many of them. On to the delivery of evidence-based treatment for multiple anxiety disorders in primary care. This is American mental health care at its most up to date, i.e. indistinguishable from British mental health care, and a world away from the bearded man sitting at the end of the patient's couch who still appears regularly in New Yorker cartoons. Instead the anxious patient (or should I say client?) sits in front of a computer doing CBT. If this is deemed insufficient, then serotonin reuptake inhibitors are allowed, following a web-based optimization schedule. Then, if all else fails, give them some diazepam. This is known as CALM (Coordinated Anxiety Learning and Management) and it proved superior to Usual Care in 17 US primary care clinics.
1938 Traumatic brain injury does not do wonders for your mood. Over half the patients in this cohort of brain-injured patients from Seattle were deemed to have major depressive disorder. This in turn was a predictor for poorer health-related quality of life. The figures were based on a recruitment rate of 52% and telephone interviews using PHQ-9, so the figures aren't the most robust. I'd also like to know how many of these patients have undetected pituitary dysfunction. Also we don't know what interventions might work best for these people; and from watching Frasier I have concerns about the quality of psychiatric services in Seattle.
1954 It's been known for years that depression is one of the worst single predictive factors for death and hospitalization in end-stage diseases such as heart failure and advanced pulmonary disease. Here the same is found for chronic kidney disease. Some of this may be to do with the will to live; some of it is also no doubt due to all the feel-bad chemicals (such a cytokines) that accompany the dying process in these advanced disease states.
1961 Are men allowed to have postnatal depression? I think the answer from this meta-analysis of 43 studies is: not really. The men who became depressed after the birth of a child were generally the men who had depression before and who were reacting to a new stressor, in the form of the baby or its depressed mother. Maybe this is what Freud meant when he told Mahler that he was much too neurotic to father children.
1970 Progress in psychiatry in my working lifetime has meant a fall in the suicide rate and an increase in the number of people taking long-term drug treatment. Some drugs are slightly better than the ones I started out with; most are just a lot more expensive. Psychopharmacology works in the most mysterious ways its wonders to perform. It seems that you can make people feel better either by inhibiting serotonin reuptake or promoting it. Serotonin reuptake inhibitors aren't meant to be addictive but most people feel worse when they stop them. The newer ("atypical") antipsychotics may be more toxic than the phenothiazines they replaced. Benzodiazepines have become an absolute taboo, but I don't see in what ways they are worse than the drugs that we are supposed to prescribe instead. The way out of this morass is going to come with better understanding of genomics, according to this interesting short editorial, Rethinking Mental Illness. Or rather, because genomics is proving useless at uncovering most of the determinants of mental illness, the answer will lie in epigenomics - how life exposures influence the expression of genes. The authors find "strong bases for hope that insights emerging from genetics and neuroscience will be translated into rational development of robust and personalized treatments." Lift up your hearts. R: We lift them up unto the genes, O Lord.
NEJM 20 May 2010 Vol 362
1863 British studies of endovascular versus open repair of abdominal aortic aneurysm dominate this week's New England Journal: there are two of them, or three, if like Andrew Marvell you regard the Netherlands as just a few bits of England that have washed up on the other side of the North Sea:
HOLLAND, that scarce deserves the name of Land,
As but th'Off-scouring of the Brittish Sand;
And so much Earth as was contributed
By English Pilots when they heav'd the Lead;
Or what by th' Oceans slow alluvion fell,
Of shipwrackt Cockle and the Muscle-shell;
This indigested vomit of the Sea
Fell to the Dutch by just Propriety.
The Character of Holland (?1653)
In the interests of friendly relations between our two kingdoms I should hasten to add that the British and the Dutch studies here concur and that renewed naval conflict is unlikely to be required at this time. The British data come from two studies called EVAR, with a median follow-up time of 6 years from randomisation to either open surgery or endovascular repair in EVAR-1. Although there was an initial mortality benefit from endovascular repair, this had disappeared by two years and there was a higher rate (30%) of additional procedures in this group. Unfortunately the rate of major operative complications of open repair (e.g. wound hernia) is not given, but the editorial (p.1930) uses US registry data to suggest that these are common and important and probably mean that the two procedures are equally good and equally hazardous.
1872 EVAR-2 looks at the effect of endovascular repair or no treatment in patients with too much comorbidity to be considered for open repair. Those operated on die less from their aneurysms but overall die just as quickly as those left alone.
1881 The Dutch Randomized Endovascular Aneurysm Repair (DREAM) study was no mere off-scouring of the British ones but an entirely independent large trial which reached exactly the same conclusion - initial benefit from endovascular repair, but long-term mortality equivalence and more complications.
1901 Although I am forever deriding the contribution that genomics has so far made to the practical business of medicine, I am at heart an honest and nobly scientific creature whose greatest delight will be to be proved wrong in the fullness of time. So I commend to your attention this Brief Report (8 pages) on L-histidine decarboxylase and Tourette's syndrome. The investigators examined a unique kindred (family to you and me) with autosomal dominant heritability of Tourette's, which is otherwise a sporadic disorder with 10-15% recurrence in first-degree relatives. They were able to identify a genetic locus for Tourette's in the HDC gene which encodes for L-histidine decarboxylase. This may soon translate into a pharmacological treatment for Tourette's, because work has already been going on for years on the pharmacology of the presynaptic autoreceptor H3R and its role in Tourette's. So although genomics cannot take the credit for starting this search, at least it supports its logic.
Lancet 22 May 2010 Vol 375
The Lancet has gone nobly global this week, mostly on the subject of tuberculosis. This is what the editor Richard Horton does best, and it won't benefit from the comments from a middle-English GP who rarely sees any TB. You're best to go straight to the papers of interest - about early treatment outcomes and HIV status in extensively resistant TB in South Africa (p.1798)
and the wide-ranging, magisterial surveys on p.1814 - tuberculosis control and elimination 2010-50
- and on p.1830 - multi-resistant and extensively drug-resistant tuberculosis.
For the general reader in relatively TB-free countries, Horton's "Offline" page (p.1766) continues to provide a pleasant diversion full of surprising insights and unexpected modesty. The "Art of Medicine" section on TB (p.1774) however strikes me as a great opportunity missed. We get a picture of TB in Australia in the past to compare with HIV now. What we might have had is a discussion of the effect of TB on literature and music: imagine Keats growing old writing verse plays to rival Shakespeare, and epics of the soul complete and luminous, of the sort he started to sketch with Hyperion. Schiller likewise in Germany would have created magnificent new texts set to music by Weber (and by Schubert too, had syphilis been conquered). A golden age of gentle humanity would have settled over central Europe as these men and Chopin continued to write masterpieces until their deaths in the 1870s and 1880s. Upstarts like Wagner would have found no place and Prussian militarism would never have taken root with deadly effect. Chekhov in Russia would have continued to celebrate and transform the human spirit right up to the 1940s, a decade of universal peace and plenty. Ah me, I fondly dream. Mycobacterium tuberculosis got there first.
BMJ 22 May 2010 Vol 340
1120 I started prescribing antibiotics in primary care in the mid-1970s, when the commonest ones were amoxicillin, erythromycin, cefalexin and co-trimoxazole. They usually worked, though we were told that in a few years they might become useless due to bacterial resistance thanks to overprescribing. Nowadays I prescribe the same antibiotics (though trimethoprim alone rather than as co-trimoxazole); they still usually work, though here is another paper telling us they might breed resistance in individuals and hence in the community. And that is true: the people for whom they work least well are the ones who most need them - those with recurrent UTIs, COPD and bronchiectasis, who get repeated courses. But nobody is suggesting we should stop giving them to these people. Whether we should give fewer antibiotics to healthier people is a moot point, about which I have no strong convictions. I don't think it greatly matters, as they will get them much less frequently than every 12 months. That seems to me the message of this immensely diligent meta-analysis, though it's not the conclusion of the authors, who take the Orthodox Calvinist position.
1122 Accelerated recovery from ankle sprain is the one subject I have contemplated the most in the last month. I hobbled home after I had done it and observed the increasing swelling with bemusement. I went to bed but woke up with the pain and found myself unable to bear weight, so I went to A&E. It was only after a clear X-ray that I had enough sense to put some ice on it and keep it up properly. Blood breakdown products tracked around in the most interesting fashion over the next few days, causing a stinging inflammation wherever they emerged, remote from the point of injury. This is my patient narrative and I hope it has increased your empathy. Now for the business: does early therapeutic exercise in the first week produce a better functional outcome than standard PRICE? I can't really answer the question personally as I got very bored of lying with my leg in the air and reading a learned work about Akhenaten, and besides I was on my own and needed to eat. This randomised trial found some functional advantage for active rehabilitation after one week, little difference thereafter. I suspect it doesn't make much difference in the real world - ankle sprains get better whatever you do.
1124 Multiple sclerosis is a disease of sun-deficient countries, which has given rise to the hypothesis that low maternal vitamin D during pregnancy may play a role in its pathogenesis. Support comes here from an historico-metereological study from a MS register which gives the dates of birth of Australian MS patients. Examine this and then estimate the amount of ambient ultraviolet radiation during gestation from weather records and you get the expected inverse link with MS, particularly if you look at the first trimester. Ingenious.
1125 When I first conceived a BMJ series to be called "Commoner Than You Think" 8 years ago, high on the list was antiphospholipid syndrome. But when the series finally emerged as Easily Missed, I was told that the syndrome was already earmarked for a Clinical Review, and here it is. This is a much better format for going into detail about this intriguing and distressing range of conditions, which can be anything from recurrent miscarriage to multiple arterial infarcts, first identified 27 years ago. This article from Holland continues the high standards of these BMJ disease reviews. But I gawped at the advice given in the final sentence:
"We advise that any patient with a suspected antiphospholipid syndrome should be seen by a multidisciplinary team of specialists that ideally includes a rheumatologist, haematologist, neurologist, nephrologist, and obstetrician for diagnosis, treatment, and education." Any patient with suspected antiphospholipid syndrome? Surely this list should include a porcine aviation facilitator.
Ann Intern Med 18 May 2010 Vol 152
621 Deprive a chap of androgen, and his bones begin to thin. So at what point should you be thinking of using a bisphosphonate? Here's a cost-effectiveness modelling exercise from the USA, based on the case of a 70-year-old man with prostate cancer starting anti-androgen therapy. The advice that emerges from the Markov state-transition model is to do bone density measurement first and only give alendronate to men who are osteoporotic already, or at high risk of hip fracture. But to apply this to a UK context, you would have to factor in an entirely different set of costings, which somebody now should do.
630 From time to time I have tried to fill you in with the emerging literature of non-invasive testing for coronary artery disease, and in particular computed tomography coronary angiography. This may grow in importance as stress testing fades away under the new NICE guidelines. But like all tests, its predictive value depends on the pre-test probability, in this case of coronary artery disease. Once again we go to Marvell's Holland to get a good thorough Bayesian analysis of the value of CTCA based on their patients in Rotterdam. They conclude that this kind of imaging is most useful in the intermediate probability range. Those with low pre-test probability can be given the all clear after a negative stress test; those with a high probability should get a proper angiogram.
Plant of the Week: Erodium chrysanthum
The erodiums are small members of the geranium family, with pretty and usually abundant flowers over a long period. They make ideal fillers for every small space of bare earth you may happen to have. Most of them have colours in the usual hardy geranium range from white through pink to streaky purple. But this Greek erodium has flowers of pale primrose, and to my mind it is the best.
I once found it on a market stall and then lost it during a hard winter. I looked for another but a specialist alpine nurseryman assured me he knew of no such plant. Then I found it last year in some garden centre, and its wonderful cut silvery-green foliage has shown no fear during the worst winter for three decades: it even started flowering in late March, and it will continue until autumn. I suspect it comes with varying degrees of vigour and hardiness. Anyway, look out for it and buy it as soon as you see it. Despite my experiences, the Plant Finder classes it as "widely available".
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