May 8th, 2014
Selections from Richard Lehman’s Literature Review: May 8th
Richard Lehman, BM, BCh, MRCGP
CardioExchange is pleased to reprint this selection from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.
NEJM 1 May 2014 Vol 370
Darapladib for Preventing Ischemic Events in Stable Coronary Heart Disease (pg. 1702): Britons, mourn. Our biggest drug company, GlaxoSmithKline, had a potential blockbuster on its hands. Darapladib would stabilise unstable plaque, everybody would want to take it, and GSK would make billions. But, although darapladib is a selective oral inhibitor of lipoprotein associated phospholipase A2, which is an enzyme associated with plaque instability, 8000 people with stable coronary artery disease took it for three years with outcomes no different from the 8000 people who took placebo. Britons rejoice. The NHS will not have to pay for millions of prescriptions for darapladib. We have enough wonderfully effective substances already for the secondary prevention of cardiovascular events: fruit, fish, alcohol, aspirin and statins. And nuts.
BMJ 3 May 2014 Vol 348
Discrepancies in Autologous Bone Marrow Stem Cell Trials and Enhancement of EF (DAMASCENE): A while back I suggested in these reviews that the major journals should refuse any further papers about stem cells for regenerating myocardium until one of them showed some positive effects on patient important outcomes. Ten years ago, this concept was exciting and it was reasonable for hope to triumph over cold reality; but, as the reality has stayed cold, the converse now applies. Yet, as a recent Cochrane review update suggested, there are some studies that have faintly positive outcomes, though with a high risk of bias. Darrel Francis and the DAMASCENE team went further and performed the exacting task of looking at all the trials to discover whether their sums add up. The results of this brilliant analysis are quite damning: there was a direct relationship between figures that contradicted each other and alleged increases in ejection fraction following autologous bone marrow cell administration.
Dietary Fiber Intake and Mortality Among Survivors of MI: People who go out of their way to eat cereal fibre (The BMJ actually spells it “fiber” here) are not typical. They are “health conscious” and are likely to wear sandals, ride bicycles, grow their own vegetables, and all sorts of other things that I might do myself were I ever to acquire the skill and inclination. They have a low risk of myocardial infarction and a higher chance of surviving it if they do experience an event. This is not surprising. What is surprising is that anyone supposes you can isolate this component of behavior (sic) while adjusting for all the rest.
Book of the Week: The Science of the Art of Medicine by John Brush
Like all of you, I rarely read a medical book at all, let alone from cover to cover. It’s become a truism that all medical texts are out of date before they are printed. This book is a rare exception, and I would even go so far as to say that it will be read in a hundred years’ time and still have valuable things to say. Moreover it does not have covers and it is not printed.
You were among the brightest of your class at school. When you got a place at medical school, you realised that you only had to persevere for five or six years, well within the limits of your abilities, and you would have a job for life. You were taught innumerable facts and skills, and then you were cast into the real world of hospital medicine. You were often tired, you sometimes wished for patients to die so that you could get some sleep, you made mistakes and they did die, and you lay awake and wondered what you should have done differently. Gradually you learnt your own coping skills: things first done arduously became instinctive, and you also learned through the camaraderie of those who shared your stresses, mistakes, and triumphs.
That is how you learned the “Art of Medicine.” Do you feel it was the right way? Do you feel you now know how to do it better than anyone else? If so, there is absolutely no need to read John Brush’s book. You should instead write one of your own. But I bet it won’t be as good.
Here is a fuller account of what I think about it. It is free, it is beautiful, and it is short. I defy any clinician to read it and not benefit.