JOURNAL SNIPPETS

JAMA 20 Oct 2010 Vol 304
1693 There was a time when the professor of surgery wouldn't know the names of his immediate juniors, and surgeons who regularly made their nurses cry and threw instruments in theatre. For a few young men, these became heroic role models: the rest were put off surgery for life. "There is insufficient information about the effectiveness of medical team training on surgical outcomes," according to this study of team training in US Veterans' hospitals. They found that such training brought about a 50% fall in mortality rates. Further studies should include Kleenex counts among operating room staff.
http://jama.ama-assn.org/cgi/content/abstract/304/15/1693

NEJM 21 Oct 2010 Vol 363
1597 There is probably at least one patient with aortic stenosis who is considered too poor a surgical risk for open valve replacement and who will therefore become increasingly symptomatic and die within a couple of years. In the future, such patients will face a difficult choice: whether to go for trans-catheter aortic valve replacement, which involves a bovine valve being implanted via a femoral artery catheter and expanded with a balloon. This is as tricky as it sounds and carries a 5% risk of stroke and a 16% risk of major vascular complications; on the other hand, in this randomised study (TAVI) 70% of the patients randomised to catheter valve replacement were alive at one year compared with 50% of those randomised to standard treatment (which could include balloon valvuloplasty). http://www.nejm.org/doi/full/10.1056/NEJMoa1008232

1608 About ten years ago, The Lancet (less pompous in those days) published a picture of a piece of glass at an angle of 45 degrees with trickles of blood running down it. This was a patient's way of measuring his own INR while taking warfarin on a trip to remote China. Nowadays there are expensive home testing kits which do the same thing. Here is a trial that compares weekly home testing with monthly standard lab testing in patients taking warfarin for atrial fibrillation or valve replacement. Fortunately it was funded by the Department of Veterans Cooperative Studies Program, rather than a diagnostics company, and it concludes quite simply that "These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy." If a testing kit manufacturer had paid for it, it probably would have read "Self-testing shows significant benefits in time within target INR range and patient satisfaction, with no increase in stroke, major bleeding episode or death.
http://www.nejm.org/doi/full/10.1056/NEJMoa1002617

Lancet 23 Oct 2010 Vol 376
1393 When you see the title of this paper: A multilocus genetic risk score for coronary heart disease: case-control and prospective cohort analyses, you will need to read right though it, because the abstract is of little help. "Using a genetic risk score based on 13 SNPs associated with coronary heart disease, we can identify the 20% of individuals of European ancestry who are at roughly 70% increased risk of a first coronary heart disease event." But what the Finnish investigators discovered was a difference of 70% between the lowest and highest quintiles in their gene-carriage score, which is not the same thing at all: it probably means a risk increase of about 30% compared with the mean. And factoring in these SNPs adds nothing to existing cardiovascular risk scores. The vast amount of work these investigators put in to this analysis of the FINRISK and COROGENE cohorts seems doomed from the start: as the accompanying editorial states, "it seems unlikely that genomic risk prediction alone will attain the discriminatory resolution to predict individual disease-risk for many common diseases with only modest heritability." In other words, if a disease isn't already strongly predictable from family history, trawling through billions of gene pairs to identify candidate SNPs and doing case-control studies to achieve p values of less than 10-6 is likely to be a waste of time. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61267-6/abstract