New Eng J Med Vol 353
1555 We now know that immunity to whooping cough, whether from infection or vaccination, is not life-long, and that pertussis can cause chronic cough at all ages. A new acellular vaccine looks promising as a booster for adults.
1659 Trastuzumab (Herceptin®) really is a breakthrough in the treatment of the most aggressive form of breast cancer, the type expressing epidermal growth factor receptor 2 (HER2), which allows rapid growth and metastasis. It's nothing to do with ER, which is the oestrogen receptor. If you use the monoclonal antibody trastuzumab to bung up the HER2 receptors, you change the entire potential of the cancer. Three trials used it alongside chemotherapy in localised disease, with impressive results.
1784 But is the fall in breast cancer mortality over recent years due to better treatment or to mammographic screening? It's an area of fierce debate (see the book review in Lancet page 1519), and this study uses seven different mathematical models, assessing the contribution from screening at between 28 and 65%.
1810 Brain drain figures for doctors — the main exit is from India, and the NHS depends on overseas workers for 28% of its medical workforce.
1889 If the exercise ECG report reads ‘unable to complete Bruce protocol due to breathlessness’, the patient has a worse outlook than if it reads ‘positive for ischaemia’.
1945 A useful review of bacterial infections in intravenous drug users.
Lancet Vol 353
1359 All case-control studies of nonsteroidal anti-inflammatory drugs show a doubled (or worse) risk of cardiovascular events, but at least they probably reduce the risk of oral cancer.
1379 An Italian study confirming that provided your hepatitis B vaccine has made you immune, you don't need a booster.
1443 One vaccine that never guarantees protection is BCG, but a study of Turkish children in households where a parent had TB does show that it lowers the risk of infection by about 40%.
1471 A good single author review of self-harm, recommending close patient support, as well as the more general measures which feature in a meta-analysis in JAMA page 2064.
1538 There was a big drop in trauma deaths in the UK from 1989 and 1994, but not much progress since. For head injuries, the answer may lie in more use of neurosurgery centres.
1545 Looking at the figures of this big meta-analysis of β-blockade in hypertension, I'm struck by what good drugs they are, provided you avoid atenolol. The authors damn them all.
1607 If you find clopidogrel hard to get your tongue round, think of the thousands of Chinese doctors who took part in this trial, which proves that it should be given in addition to aspirin for all patients with acute myocardial infarction.
1640 Yet another global study showing that body mass index is less predictive of cardiovascular risk than waist measurement: waist-to-hip ratio is even better.
JAMA Vol 294
1765 Most women with breast cancer die of something else, especially if they are poor and black and live in the US.
1903 The only lasting cure for obesity in most people is bariatric surgery, but at 4.6%, the 1-year mortality in real life is much higher than in the trials.
1934 Are there any safe drugs to suppress psychotic behaviour in people with advanced dementia? All the newer ‘atypical’ drugs have risks, with an overall odds ratio for death of 1.54%.
2188 Think of any children in your practice who have neurological problems, and vaccinate them against influenza. These are at greatest risk of death if they get severe illness.
Other Journals
A multinational cohort study of blood pressure in Arch Intern Med (165: 2142) confirms what Framingham has already been telling us — it's not the systolic or the diastolic but the difference between them that most determines outcome. Beware a pulse pressure higher than 60. If you want a thoughtful summary of the Polypill debate, go to Ann Intern Med (143: 593). The next issue contains several papers about a common contributor to mortality in the elderly — anaemia (see pages 2214, 2222 and 2237). There's a cheap, natural substance that decreases the risk of cancer death by a third, according to a meta-analysis bearing the seal of no less than Gordon Guyatt. It's melatonin, as you'll already know if you subscribe to the J Pineal Research (39: 360).
Plant of the Month: Helleborus niger
The Christmas Rose won't grow for a Scrooge like me, but maybe you are able enjoy its beautiful white flowers. Bah!
- © British Journal of General Practice, 2005.