This week's journal reviews on Doctors.net.uk
Journal Watch is a service provided to summarise some of the most popular medical journals.
Doctors.net.uk has a panel of specialist advisers responsible for reviewing a range of journals of general medical interest and some more specialised publications.
General Journal Watch is written by Dr Druin Burch, Consultant in Internal Medicine
This week's journals include...
Beyonce, Mariah Carey and the Lancet
If you want sparkling writing in the Lancet
, this page does the best job this week of providing it. The subject is an award-winning soul singer, and I can't begin to tell you how little I care about soul music or its singers. Yet if writing like this could appear on topics of actual importance, like DSM-V and the Health and Social Care Bill, the journal would be a brighter place.
Enoxaparin is better than heparin for PCI
If you flick to the 'What is already known on this topic' section, perplexed as to whether there was any doubt about the superiority of enoxaparin over heparin for percutaneous coronary intervention, you'll be rapidly re-assured that there was none whatsoever. What's the point, then, of this overview of the evidence? Actually it seems very useful. The gap between guidelines and evidence is notably wide. "The current updated guidelines for anticoagulation in patients requiring percutaneous coronary intervention for ST segment elevation myocardial infarction produced by the American College of Cardiology, American Heart Association, and Society of Cardiac Angiography and Intervention as well as guidelines from the Task Force on Myocardial Revascularization of the European Society of Cardiology continue to afford unfractionated heparin a class 1 recommendation for this indication, despite limited supporting evidence (level of evidence C)." This meta-analysis shows an advantage for enoxaparin over unfractionated heparin in reducing mortality by a third. Since the absolute risk of death is small, that converts to an absolute risk reduction of around 2%. If that sounds minimal to you, it shouldn't: it's about the same, for example, as that provided by thrombolysis in pre-PCI days.
Semuloparin for thromboprophylaxis in cancer patients receiving chemotherapy
I rant, on a weekly basis, about a number of things. Recently I've kept on about the woolly toothlessness of Lancet
editorials on important subjects - they're reminiscent of Denis Healey's famous comment that being attacked by Geoffrey Howe in Parliament was "like being savaged by a dead sheep". I can make the point in a different fashion by quoting the review of this article written by my friend Richard Lehman for his BMJ
blog. It's precise in its accusations, gives its reasons and executes that seems to me an appropriate demolition without bluster or windiness - compare it with the longer and more waffly Lancet
offerings. I also can't do better myself, so here it is for that reason also. "It’s a familiar pattern: a pharma company (Sanofi in this case) pays for a trial based in 395 centres across 47 countries, in order to study the effect of its new drug semuloparin on the outcomes of 3,172 patients receiving chemotherapy for solid tumours. The duration of the trial is 3.5 months and the endpoints are venous thromboembolism, bleeding and overall survival: the comparator is not a different low molecular heparin, but placebo. Sanofi writes up the study, with the bottom-line conclusion: “Semuloparin reduces the incidence of thromboembolic events in patients receiving chemotherapy for cancer, with no apparent increase in major bleeding.” Result: semuloparin continues to be used in most of the 395 centres and Sanofi is free to buy shed-loads of reprints from the NEJM
in order to encourage clinicians to believe that their product is the one best proven to prevent VTE in chemo patients. The NEJM
is free to sell these reprints without disclosing this to anyone (for “commercial reasons”), but can salve its conscience by printing an editorial criticising the study for undue commercial bias. Both parties are winners, and cancer patients can now be treated on the basis of 3.5 months’ worth of outcome data, most of which will not even be in the public domain. This is nothing exceptional – it is the standard model of evidence-based medicine in 2012."
Amoxicillin for acute rhinosinusitis
Do you, dear reader, have at your fingertips the Sinonasal Outcome Test-16 ? I assume, as an educated doctor, that it comes to your mind more easily than the remembrance of your first love. You'll be interested, then, in this trial looking to see whether amoxicillin makes any difference to symptoms of acute rhinosinusitis. Oddly the primary outcome was the symptomatic benefit at day 3, while the treatment course actually lasted for another week. Regardless, the primary outcome was negative.
Homocysteine and coronary heart disease
Homocysteine was a wonderful target for research. It was consistently associated with heart disease risk and everything pointed toward this being a causal link rather than merely an association. On top of that, homocysteine lowering is easy and safe with vitamins B6, B12 and folate. No surprise then that a large number of intelligent, thoughtful and compassionate scientists devoted their careers to the subject. Sadly for us, and even more sadly for them, the link between homocysteine and cardiovascular badness turns out to be an association after all. This has been known with confidence for some time, but this study of 'Mendelian randomization' hammers the nail more firmly into the coffin's plywood. In those with a genetic pre-disposition for high homocysteine, risks are no higher than for those without.
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