19 Nov 2008  Vol 3002253   The heyday of the ginkgo tree was the Jurassic period when forests of Ginkgo adiantoides towered over even the largest dinosaurs. The whole genus was thought to be extinct until the eighteenth century when G biloba was discovered in remote eastern China; following which ginkgos have enjoyed a second golden age as widely planted ornamental trees around the world. Moreover this ancient tree is widely believed to contain a mystical elixir which prevents dementia. If only. This US trial in 523 people aged 75 and over had a follow-up period of six years and in that time slightly more of those randomised to ginkgo extract developed Alzheimer’s or other dementia.  http://jama.ama-assn.org/cgi/content/abstract/300/19/22532277   Bevacizumab is a monoclonal antibody directed against vascular endothelial growth factor and for mab-challenged readers I should mention that it is widely used as a last-ditch agent against a variety of cancers. It has acquired a reputation for increasing the risk of venous thromboembolism and this meta-analysis wrestles with the question of how big an added risk this might be in patients with a variety of malignancies which can themselves increase the rate of VTE and which often kill patients in the time scale of the trials. Bevacizumab probably increases VTE by about a third overall: what we can do about it is uncertain.  http://jama.ama-assn.org/cgi/content/abstract/300/19/22772286   We know that morbid obesity is bad for fertility so does bariatric surgery improve pregnancy rates? Unfortunately this systematic review finds that existing studies don’t permit a definite answer though it’s likely that women who have lost a large part of their excess weight following bariatric surgery have fewer adverse maternal and neonatal events.  http://jama.ama-assn.org/cgi/content/abstract/300/19/2286NEJM  20 Nov 2008  Vol 3592195   In the JUPITER trial the manufacturers of rosuvastatin recruited 17802 subjects with healthy levels of LDL cholesterol – men aged 50 and over and women aged 60 and over – with slight elevation of high-sensitivity C-reactive protein (>2mg/dl) and gave placebo to half of them and 20mg of their product to the rest. Although healthy individuals to meet these criteria abound in every location AstraZeneca involved 1315 sites in 26 countries – perhaps in honour of the god Jupiter who was a well known practitioner of seeding. Indeed this was one of his main roles as father of the gods (for a naughty illustration see Wikipedia). Another of his roles was to make a big noise as the thunder god Juppiter tonans. This trial certainly did that in exactly the way its sponsors would have liked. But does it really prove as all the newspapers reported that we should give rosuvastatin to everybody from middle age onwards? That would certainly reduce major adverse cardiovascular events but the strange design of the study makes it hard to extrapolate to the whole population or indeed any definable clinical population (how often do you measure high-sensitivity CRP?): an editorial later in the journal (p.2289) raises some pertinent questions but for once the editorial in the BMJ (p.1182) is even better by Jove.  http://content.nejm.org/cgi/content/abstract/359/21/21952208   In this week’s Lancet a Profile of Sir John Bell Regius Professor of Medicine at Oxford and President of the Academy of Medical Sciences has him confidently asserting a future for “personalised medicine” meaning medicine in which you don’t so much encounter persons as predict illnesses from their genome. To you and me personalised medicine for type 2 diabetes means meeting a lot of mostly fat people over 60 whose arteries tend to fur up whose feet go numb and septic and whose eyesight often fails and helping them cope as best they can. But the task for prestigious doctors is to predict type 2 diabetes from a genotype score. To judge from the study here and the one that follows on p.2220 they are rubbish at it http://content.nejm.org/cgi/content/abstract/359/21/2208
http://content.nejm.org/cgi/content/abstract/359/21/22202245   A recent study showed that dropping dead after myocardial infarction has become less common but it is still a considerable risk if you develop left systolic dysfunction with adverse cardiac remodelling or if you show a high rate of ventricular arrhythmias on ambulatory monitoring weeks after the event. In such cases you might do well to be fitted with an implantable cardioverter-defibrillator unless your heart failure has reached the point at which you would prefer to drop dead anyway. This clinical review discusses the indications for ICDs following MI in detail.  http://content.nejm.org/cgi/content/extract/359/21/2245Lancet  22 Nov 2008  Vol 3721835   The best thing – in fact the only thing of general interest – in this week’s Lancet is this seminar on age-related macular degeneration. It is a disease which is commonest in white people and smokers and of course it increases with age. No preventive treatment has been shown to be effective and regimes which include beta-carotene carry an increased risk of lung cancers. Only a few individuals will benefit from laser treatment though lots benefit from photodynamic therapy with verteporin except for an unfortunate 3-4% who experience severe deterioration. As for the place of intravitreal becavizumab (relatively cheap but unlicensed) versus the vastly more expensive ranibizumab there are no current trial data but a head-on randomised trial has at last begun.  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61759-6/abstractBMJ Journals  Nov 2008ADC  952  Here are the results of a national UK audit of children admitted with acute wheeze/asthma during the month of November in the years 1998-2005: interesting reading for anyone who looks after wheezy kids. There are wide variations in practice between hospitals in the UK but the most consistent finding is a reduction in the use of nebulised therapy over recent years in favour of therapy delivered through spacers. Too few children admitted with asthma go home with clear treatment plans or with their inhaler technique properly checked.  http://adc.bmj.com/cgi/content/abstract/93/11/952Heart  1364   Just now aspirin needs all the friends it can get with John Cleland on his familiar anti-aspirin warpath in the BMJ correspondence and the Polypill in danger of dwindling down to an evening dose of statin. This editorial revisits the evidence for giving aspirin to all over the age of 50. It is curiously non-committal though it makes the important point that although aspirin carries a risk of bleeding such events are usually much less serious than the events which aspirin prophylaxis may prevent particularly stroke.  http://heart.bmj.com/cgi/content/extract/94/11/1364Heart  1407  Back in the 1970s when I was a house officer medical takes consisted of a stream of men in their forties and fifties who had myocardial infarction and who would have had a lower mortality had they been kept at home. Now that hospitals deliver treatment that actually helps patients rather than kills them how do most people with ST-elevation MI fare in the UK? In this national audit 90% survived their stay: those who were given aspirin immediately and had out-of-hospital thrombolysis had the best outcomes.  http://heart.bmj.com/cgi/content/abstract/94/11/1407Ann Intern Med  18 Nov 2008 Vol 149698   Following deep vein thrombosis many people get varying degrees of leg discomfort. This Canadian study set out to investigate the size and time-course of the post-thrombotic syndrome including swelling cramping and heaviness as well as pain. The bigger and higher the clot the more severe the symptoms which did not change very much over the 24 months of the study: mild in 30% moderate in 10% severe in 3%.  http://www.annals.org/cgi/content/abstract/149/10/698708   The default setting in type 1 diabetes is death and most GPs will recollect some young patient who couldn’t come to terms with the condition and succumbed to insulin coma or less commonly to ketoacidosis. It can be something of a nightmare trying to improve motivation in such patients and that is confirmed in this British study of motivational enhancement therapy with or without cognitive behavioural therapy versus usual care for poorly controlled type 1 diabetics. Nurse-delivered motivational therapy on its own had no effect while combined with CBT it delivered a drop in %HbA1c of 0.46. Not much to show for an unfeasible amount of encouragement.  http://www.annals.org/cgi/content/abstract/149/10/708720   You may be a doctor but do you have healing skills? This study looked at the common ground between 50 practitioners considered particularly good at relating to their patients: 10 of them were from the “alternative sector”. If you’ve ever done any communication skills training you won’t be surprised at most of the themes that emerge though you might prefer them served up with a smaller helping of corn syrup. If you start with a real interest in your patient most of the rest will follow.  http://www.annals.org/cgi/content/abstract/149/10/720734    It’s a rare day in general practice when you don’t have to decide on which second generation antidepressant to prescribe and here is a massive evidence base to help guide your choice: a 37-page analysis of 299 studies prepared for the American College of Physicians. The result: they all work equally well as far as anyone can tell. Mirtazapine probably starts working faster than most others: bupropion (which for some reason isn’t licensed for treating depression in the UK) has the fewest sexual side-effects paroxetine the most. And about the important issue of habituation and withdrawal we don’t seem to know nearly enough.  http://www.annals.org/cgi/content/abstract/149/10/734751    We spend a fair amount of time trying to share decision-making with patients and I suspect that if we had twice as much consultation time8bf we would do it twice as well. As it is I’m constantly on the search for short cuts to explain risk to people in a meaningful non-biased way so I pounced on this paper eagerly. Alas it provides a long cut rather than a short one: risk stratification tables may be good for academics wishing to refine their methodology but of little use to jobbing doctors.  http://www.annals.org/cgi/content/abstract/149/10/751Plant of the Week: Jasminum nudiflorumThere isn’t much to say about winter-flowering jasmine: it is common propagates with the greatest ease provides a bit of yellow cheer through December and January and is best planted where it can sprawl at will. But what a fantastic plant it could be with only the simplest bit of genetic engineering. A slight change to its colour genes and it could be a soft cream or even pink; a gene splice from almost any other jasmine and it could carry the scent of summer evenings into the depths of winter; another might make it evergreen. Come on all you gene gnomes: we need you in our gardens.