JAMA 18 Nov 2009 Vol 302
2135 I like to say nice things about JAMA’s The Rational Clinical Examination series and this latest paper, Does This Patient with Palpitations Have a Cardiac Arrhythmia? maintains its high standards of thoroughness. But is this a real-life question? You feel the pulse and it’s irregular, so you do an ECG. Or you feel the pulse and it isn’t irregular, so you do a 24-hour ECG, or give the patient an event monitor (we have just acquired a nice dinky one). Rationally, the clinical examination is never enough. The one possible exception cited here is a regular rapid-pounding sensation in the neck or visible neck pulsations – this apparently signifies atrioventricular nodal reentry tachycardia. To which I would add syncope on sudden loud noises in a healthy young person, which is likely to be long QT syndrome.
http://jama.ama-assn.org/cgi/content/abstract/302/19/2135
BMJ 21 Nov 2009 Vol 339
1178 Income inequality generates bad health – this might be called the Marmot Effect, not after the personable rodent, but in honour of Michael Marmot, who first demonstrated it in the Whitehall Studies and was improbably knighted by the Major government as a result. There have been lots of subsequent studies all over the world, which are analysed here. They all show the same thing, independently of level of income.
http://www.bmj.com/cgi/content/full/339/nov10_2/b4471
1186 British general practice has led patients a merry old dance in recent years, as we’ve been incentivised to do one thing, then another, then the first thing again. If it’s had any benefit – other than to our personal income – it’s made us look very hard at certain groups of patients, notably those who have had heart disease. The QOF rules for secondary prevention are very clear, which won’t prevent them changing in the near future, when losartan and atorvastatin – which we are currently discouraged from prescribing - come off patent. Patient care plans in this context become largely a matter of rule-book medicine: they work, but soon show a ceiling effect. As you’d expect.
http://www.bmj.com/cgi/content/full/339/oct29_4/b4220
1187 Well-functioning old French people who walk slowly have a markedly increased risk of death from cardiovascular causes. This is illustrated on the front cover of the BMJ by a tortoise, which walks slowly and has a very low risk of death from cardiovascular causes. Still, it’s sweet.
http://www.bmj.com/cgi/content/full/339/nov10_2/b4460
Ann Intern Med 17 Nov 2009 Vol 151
677 All that a hand-held computer can do for me is make me swear. It is impossible to maintain the dignity and authority of age while taking one’s glasses off and squinting uncomprehendingly at an insolent little screen, while some young creature nearby rattles away at her tiny keys and comes up with all the right answers. So I am glad that the editorial which accompanies this study of a computerised handheld decision-support system to improve pulmonary embolism diagnosis sticks up for the superior utility of a proper nineteen-inch screen and a server that can do lots of things in an elegant and leisurely way. In fact the diagnosis of PE is a very good illustration of how a clinical decision rule can be applied, and I’m all for the principle of computers helping us to arrive at Bayesian applications of new diagnostic tests. It’s just those bloody little machines... And people who can use them…http://www.annals.org/content/151/10/677.abstracthttp://www.annals.org/content/151/10/748.extract
687 Many people are not very good at taking their blood pressure medication. In fact writing this has made me scuttle off to take the tiny dose of losartan that may (with a NNT of about 200 in my case) prevent me from having the stroke I might get anyway, or alternatively might never get. BP control is hugely important on a population level (see the Lancet’s piece on China, p.1765), but many people find it difficult to be an obedient member of the herd and take their pills without reminders. This trial shows that two self-management interventions can improve hypertension control: home monitoring and a nurse phone call every 2 months – preferably both.
http://www.annals.org/content/151/10/687.abstracthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961199-5/abstract
BMJ 14 Nov 2009 Vol 339
1125 Most group analyses of cardiovascular risk conclude that nearly all differences can be explained by known risk factors such as lipids and blood pressure and smoking, but this area–stratified Glasgow study is an exception. However, it did not measure event rates but a popular surrogate measure of atherosclerosis – the common carotid intima-media thickness. Glaswegians in deprived areas develop plaque in their carotids out of all proportion to known cardiovascular risk factors, including “emerging” ones like von Willebrand factor, tissue plasminogen activator antigen and all the rest.
http://www.bmj.com/cgi/content/full/339/oct27_4/b4170
Arch Intern Med 9 Nov 2009 Vol 169
1851 The thiazide diuretics have been around for 50 years, and this article celebrates them, the best of drugs for high blood pressure. They cause hypokalaemia and hyperglycaemia, but no study has ever found these to affect long-term outcomes. They may conserve bone mineral, though this isn’t discussed here. Americans always use hydrochlorthiazide or chlorthalidone: we always use bendroflumethiazide or chlortalidone. God knows why: but just keep using them.
http://archinte.ama-assn.org/cgi/content/abstract/169/20/1851
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