From the journals, November—December 2004

Richard Lehman

New Engl J Med Vol 351

2049 In this study the old-fashioned combination of hydralazine and isosorbide dinitrate showed remarkable success as an add-on treatment for improving survival with heart failure. However, as only African Americans were recruited, we do not know how generalisable this finding may be.

2058 It is about time that silly acronyms in cardiological trials rested in PEACE: this one tried out an ACE inhibitor, trandalopril, in patients with coronary heart disease but normal left ventricular function, and it had no benefit. In the similar CAMELOT study (JAMA 292: 2217), enalapril did show some benefit, but not as much as amlodipine.

2286 Two studies (the second is on page 2295) clearly show that an influenza vaccine can be given intradermally at a fifth of the intramuscular dose and produce as good an immune reaction.

Lancet Vol 364

1766 Moh's is the name given to a meticulous skin-saving technique for excising superficial tumours, not to be confused with the bar where Homer Simpson drinks. This study found no significant benefit over conventional excision: I expect the investigators said ‘doh!’ and had a beer.

1857 One hundred thousand Iraqi civilians are dead as a result of the invasion, according to the analysis here, although Sheila Bird (page 1831) finds the figure too conservative. But Tony Blair, never a man to find anything too conservative, wants to make it 13 000.

1872 For people in rich countries, by contrast, there will soon be the opportunity to use muscle-derived stem cells to repair hearts and brains.

1959 A week after the BMJ ran an editorial describing benzodiazepine hypnotics as ‘harmful’, here is a wide-ranging review pointing out that they work well in the short term, but that a better long-term solution is cognitive behavioural therapy. Tell that to your PCT when they next audit your benzodiazepine prescribing.

JAMA Vol 292

2243 ‘But why am I just getting fat around my middle, doctor?’ Resist impolite replies, and mutter ‘dehydroepiandrosterone deficiency’. For a long time this was a hormone in search of a function, but now it has been found to reduce abdominal fat and insulin resistance in older people.

2343 Left ventricular hypertrophy (LVH) is usually measured by ECG, which misses most of it. Even echocardiography is not very accurate, but both ECG and echo-LVH are predictive of adverse events in hypertension, beyond the level of blood pressure itself. These observations from the LIFE study also confirm the value of reducing LVH.

2471 In the overweight/obese range, every additional unit of BMI carries an additional 4% risk of developing atrial fibrillation (AF).

2495 Diabetes is another obesity-related risk, but the cardiovascular harm of diabetes seems to have gone down by 50% between 1950 and 1995 — before most of us were using statins and aiming for tight control of blood pressure.

Other journals

Arch Intern Med (164: 2241) looks at the prevalence of chronic fatigue syndrome in a US community: only 14 out of 90 cases had been diagnosed previously. On page 2266 a study looks at an adverse effect of influenza vaccine — oculorespiratory syndrome. This is mild, fairly common, and can recur after revaccination: on the other hand, serious reactions like Guillain-Barré syndrome are very rare (see New Engl J Med page 2471). An exemplary Dutch study on page 2367 examines a database of people newly taking SSRI antidepressants and finds a dose-related increase in gastrointestinal bleeding. Ann Intern Med (141: 653) analyses the cost implications of going for rate control rather than rhythm control in AF, and finds them favourable. But keep the International Normalised Ratio tightly between 2 and 3 in older patients with AF, because they are at most risk of emboli or bleeding (page 745). Thorax (59: 1041) compares various dose strategies when starting inhaled corticosteroids for asthma: commencing with a standard dose seems best. Giving oral bacterial extracts to patients with chronic respiratory disease, although popular in Germany, seems to have no evidence base (Chest 126: 1645). Degeneration of intervertebral discs provides us with a lot of frustrating work: read the latest about the processes in Spine (29: 2691). A study in Arch Dis Childhood (89: 1103) confirms what we all knew: hour for hour, nursery rhymes are ten times as violent as television programmes. And then they graduate to Roald Dahl …