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The epidemiology of heart failure is a truly confusing subject. One problem is that the definition of heart failure varies so much across the many studies. One beacon in the fog is the Framingham study, which began with a definition of heart failure in 1948 and has stuck to it ever since. The Framingham criteria, derived entirely from the clinical history and examination, avoid the common trap of equating “heart failure” with reduced left systolic ejection fraction. They are also used in the Rochester Epidemiology Project, which has accumulated over 20 years of data from a much larger population in Olmsted County, Minnesota. (
). Judged by clinical criteria, the incidence of heart failure has remained almost constant amongst men in Framingham (
) and among both sexes in Olmsted County. Survival in heart failure has improved, suggesting that evidence-based medicine actually works. The improvement is much greater in those we have evidence for—the younger and male end of the heart failure spectrum. For women and the elderly, change has been much less, perhaps because we simply do not have a good evidence base for treatment. Many have a preserved ejection fraction—that is, “diastolic” heart failure—and in the UK at least, this is a condition about which no 2 cardiologists seem able to agree.
But all cardiologists agree that we should eat more fish. However, the people who share our lives may object to the lingering smell of grilled oily fish. A recent meta-analysis (
) brings comfort by lumping together all kinds of fish and finding a dose-related reduction in cardiac mortality. Still, the benefit may be greater in fish containing lots of long chain omega-3 polyunsaturated fatty acids, and these oily fish are also the best source of vitamin D. For those who don’t like herring, mackerel, or sardines and are getting tired of salmon, a greater choice is needed. Perhaps we should revive the Roman emperors’ practice of breeding lampreys for the table—although not their habit of feeding them on the flesh of slaves.
Over the past few years expensive parenteral cytokine blocking agents have tended to steal the limelight in the treatment of chronic inflammatory conditions. However, leflunomide, an orally available pyrimidine synthesis inhibitor, may prove to be of comparable benefit to people with chronic inflammatory arthritis. Already widely used in rheumatoid arthritis, it has now proved its worth in the treatment of psoriatic arthropathy in a double blind, placebo controlled RCT (
). It takes a while to work, and regular blood monitoring is needed, but there were no serious adverse effects in the 95 patients randomised to active treatment, and benefit was seen in both skin and joints.
Most doctors end up giving advice to patients with asthma in one context or another, but how much of it is evidence-based? Take, for instance, the familiar exhortation to double the dose of inhaled corticosteroids at the first sign of a flare-up. A double blinded RCT of increasing inhaled budesonide during exacerbations showed no effect (
). Nor do high-tech new treatments always fulfil their early promise. Omalizumab is a recombinant humanised monoclonal antibody (that’s what the suffix “mab” means): it is directed against IgE, and it was hoped that it might reduce allergic asthma in adults and children. A Cochrane review (
) concludes that it helps to achieve a small reduction in inhaled steroids but that its clinical value remains debatable.
Doctors are often accused of playing God, but even the Almighty is not generally expected to predict theactions of mentally disordered offenders. Still, forensic psychiatrists risk public outcry whenever they get it wrong. So several in the UK did a prospective study on the validity of scoring methods in predicting reoffending in patients discharged from a medium-secure unit (
). It turns out that a score designed to predict criminality in the general offending population (OGRS) performs better than scores weighted towards clinical and personality measures.
Mozart lovers enjoy the sublime music of The Magic Flute while politely ignoring silly bits like the brief appearance of a doctor with a giant magnet. This was a jibe at Doctor Mesmer, whose magnetic cure was all the rage in Vienna around 1790. But perhaps Mesmer has the last laugh, because magnetism really does have curative properties in depression and turns out to be particularly useful for depression associated with Parkinson’s disease. In a small blinded trial (a sham magnet was used on some), repetitive transcranial magnetic stimulation worked as well as fluoxetine, with earlier benefit and fewer adverse effects. It even seemed to help motor function (
). Maybe it really would have cured Papageno’s stutter?