NEJM 25 Nov 2010 Vol 363
2091 Quality improvement is actually, of course, a good thing in itself, and we need better ways of doing it and better ways of studying it. High quality outcomes research, carefully reflected on, is one essential input, and there are two good examples in this week's New England Journal. A general survey of North Carolina hospitals (see below, p.2124) produces a rather gloomy view of overall improvements in patient safety, but this study of mortality from allogeneic haematopoietic-cell transplantation is very much cheerier. The period 2003-7 showed an overall mortality fall of over 40% compared with a decade earlier, driven by significant decreases in the risk of severe GVHD; disease caused by viral, bacterial, and fungal infections; and damage to the liver, kidneys, and lungs. Further details are strictly for the haematologists: but it seems they have much to congratulate themselves about.
http://www.nejm.org/doi/full/10.1056/NEJMoa1004383
BMJ 27 Nov 2010 Vol 341
1144 Thrombolysis for acute occlusive stroke has been shown to be marginally beneficial in several RCTs, but the number of people over 80 in these trials is minuscule, whereas in real life, 30% of strokes occur in this age group. There is a presumption that the hazards of thrombolysis will be greater and the outcome difference less. This European registry study indicates that neither is true: thrombolysis remains beneficial for stroke beyond the age of 80.
http://www.bmj.com/content/341/bmj.c6046.full
1146 Any enthusiastic regular drinker of wine, will be delighted to note the PRIME study which confirms that by doing so you halve your chance of myocardial infarction. I suppose you also increase your chance of pancreatitis, cancers of the GI tract and stroke. Perhaps liver disease too, though the literature is surprisingly obscure at levels of intake below about 100u/week. The thing not to do is binge drink, which is a common pattern in Northern Ireland, and probably increases your baseline risk of MI. I think the further north you travel, the more dysfunctional alcohol use becomes, as warm oblivion becomes ever more desirable. As if to illustrate this point, a review of frostbite on p.1151 finds that nearly half of it is associated with alcohol use. I bet that means vodka or whisky in most cases, and wine alone hardly ever.
http://www.bmj.com/content/341/bmj.c6077.fullhttp://www.bmj.com/content/341/bmj.c5864.extract
Arch Intern Med 22 Nov 2010 Vol 170
1926 In studies of drugs that put people into hospital, warfarin usually comes near the top. This study looks at how combined platelet inhibition with aspirin plus clopidogrel compares in emergency department visits for haemorrhage-related events. The score is 2-1: 2.5 events per 1000 prescriptions of warfarin as compared with 1.2 events for aspirin/clopidogrel.
http://archinte.ama-assn.org/cgi/content/abstract/170/21/1892
JAMA 17 Nov 2010 Vol 304
2129 Like all doctors who survived their hospital jobs in the 1970s, I have some shocking memories. Oddly enough, though, some of them are happy too, as the shocks saved lives. The woman dragged out of a freezing canal with a core temperature of 28ºC who survived intact after 16 defibrillations; the 43-year old man with chest pain who went into VF just as we were putting the leads on his chest: all of us can still remember these kinds of event, while our futile attempts go forgotten days after. Surely an automated defibrillator must beat a sleep-deprived, dishevelled house doctor at achieving survival following in-hospital cardiac arrest? Actually no: another massive US cardiac outcomes study looks at the results of introducing automated defibrillators on to the wards of 204 hospitals and finds that results actually tend to be worse.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2129
2137 The harmful effects of low-dose ionizing radiation are not well understood, but from about 100mSv upwards we are no longer talking about low doses, but the kind of exposures about which we have data from Hiroshima and Nagasaki. Alarmingly, such doses were received by a third of patients in this study of repeated myocardial perfusion scanning. OK, the majority of these people were over 60 and had heart disease, and would escape long-term harm: but it suggests that we are getting too gung-ho about exposing people to high energy photons from X-ray machines and unstable isotopes, and the cumulative damage which they cause.
http://jama.ama-assn.org/cgi/content/abstract/304/19/2137
Lancet 20 Nov 2010 Vol 376
1741 Many doctors in the 1990s went through a phase of taking low dose aspirin and recommending it to many of their patients with high blood pressure and/or type 2 diabetes. Then came a series of trials which showed that it doesn't work for primary prevention of cardiovascular events, even in groups who are at increased risk. But it does prevent about 25% of bowel cancer, according to this long-term follow up study of participants in 5 large aspirin trials, matched at a median of 18.3 years with mortality registers. The results suggest that you need to take about 75mg of aspirin for at least 5 years to achieve such protection, and the effect may be specific to the proximal colon. Thus in theory universal aspirin consumption, combined with a universal programme of screening sigmoidoscopy, could prevent most bowel cancer. However, an analysis like this can tell us little about adverse events, and we will only know for certain after a prospective trial lasting at least ten years.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61543-7/abstract
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