Minerva

Never trusting uncle again and other stories . . .

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5976 (Published 09 October 2013) Cite this as: BMJ 2013;347:f5976

“On an average day in the United States, more than 100 Americans die by suicide; half of these suicides involve the use of firearms.” You can hear the National Rifle Association’s response already: don’t blame the guns, these guys would kill themselves anyway. The opening quotation is from a Harvard paper that explores the association between gun ownership in the US and suicide (American Journal of Epidemiology 2013;178:946-55, doi:10.1093/aje/kwt197). This highly sophisticated analysis concludes that firearm ownership rates, independent of underlying rates of suicidal behaviour, largely determine variations in suicide mortality across the 50 states. It does find that gun ownership itself is not a predictor of suicidality; but if you have a gun, you are more likely to succeed in killing yourself. The same applies to killing other people.

For more than a century, medical microbiology laboratories have been places full of microscopes, bottles of stains and reagents, and the sweet musty smell of bacteria growing on agar. But the traditional methods of bacteriology are finally giving way to the superior insights of whole genome analysis. How can we tell if a bug like Streptococcus pneumoniae will mooch about doing nothing or kill a child in hours? The answer may lie in analysis using multi-locus sequence typing combined with pulsed field gel electrophoresis, according to a Swedish study in the Journal of Infectious Diseases (2013, doi:10.1093/infdis/jit481). The first technique detects pneumococcal clonal types and the second detects intraclonal variants, and, using a collection of samples from 1997 to 2004, the investigators show how these variations can be linked with invasive disease potential in children.

Minerva once heard the great English cardiologist Philip Poole-Wilson (1943-2009) propose the foundation of a body called SAD—the Society for the Abolition of Digoxin. Britons have indeed moved away from prescribing digoxin for heart failure, despite their national pride in the William Withering’s remarkable work with his foxgloves. But cardiologists in North California still prescribe it as first line treatment to 18% of patients presenting with new heart failure, according to a study of Kaiser Permanente data in Circulation: Cardiovascular Quality and Outcomes (2013, doi:10.1161/CIRCOUTCOMES.111.000079). During a median 2.5 years of follow-up, incident digoxin use was associated with higher rates of death (14.2 v 11.3/100 person years) and hospital admission for heart failure (28.2 v 24.4/100 person years). You can debate the significance of these observational data, but can American faith in the foxglove survive this latest withering attack?

The drug industry has been the subject of three highly unflattering books in less than two years: Pharmageddon by David Healy, Bad Pharma by Ben Goldacre, and, hot off the press, Deadly Medicines and Organised Crime by Peter Gøtzsche. All of them cite antidepressant drugs as examples of perfidy and roundly condemn the selective publication of trials, which has allowed ineffective or harmful drugs to reach the market. The response of industry has been to say that such practices are a thing of the past and will not happen again. Agomelatine is a novel antidepressant that was approved for the treatment of unipolar major depression by the European Medicines Agency in 2009. Reviewers in the British Journal of Psychiatry (2013;203:179-87, doi:10.1192/bjp.bp.112.120196) found 13 trials of the drug, seven of which had never been published. They conclude that there is some evidence that agomelatine may be slightly better than placebo in acute depression, but that it does not prevent relapse; and there is strong evidence of publication bias. Another one for the books.

So why do doctors remain such easy targets for the drug companies? A paper in the Journal of Law, Medicine and Ethics (2013, doi:10.2139/ssrn.2286433) explores the reasons. “Six principles of influence—reciprocation, commitment, social proof, liking, authority, and scarcity—are key to the industry’s routine marketing strategies, which rely on the illusion that the industry is a generous avuncular partner to physicians.” Read the books that Minerva has listed and you will never trust uncle again.

When the great cathedrals of Europe were built, many penitents would offer their labour for free, including the French nobility, who flocked to pull carts of stone to rebuild Chartres in the 12th century. If you died in the attempt, you went to heaven all the more quickly. The medieval stonemasons, however, liked a good rate of pay for the job, and some of them grew quite rich. But their job carried more hazards than just falling off a flying buttress, as shown by a study of present day Irish stonemasons in the Annals of Occupational Hygiene (2013, doi:10.1093/annhyg/met045). Restorative stone working carries with it the risk of inhaling respirable crystalline silica, which can lead to silicosis and lung cancer.

Notes

Cite this as: BMJ 2013;347:f5976

Footnotes

  • Let Minerva know what you think of this week’s offerings at minerva{at}bmj.com.

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