iStock_70075667_MEDIUMDid you know that the health impact of sitting at a desk job for eight hours a day is as deleterious as smoking cigarettes or being obese?  That's according to a Lancet study Rick and I discuss on PodMed this week, but there is good news:  you can offset your desk jockey occupation by exercising moderately 60-90 minutes five days per week.  Enough said!  Get out there and exercise.  But first let's take a look at the data.

This study was a meta-analysis including over 1 million people for whom sitting time and mortality statistics were available.  People were divided into four groups based on their physical activity and sitting time, with the reference group sitting less than 4 hours per day and reporting the most activity.  Compared with this group, those who were the least physically active experienced mortality rates 12-59% higher than those in the reference group. By contrast, those who were physically active but also sat for prolonged periods had no increase in mortality rates.  The authors conclude that physical activity was protective against the effect of prolonged sitting.

Rick and I both speculate on the ramifications of this study, wondering if it helps further inform an appropriate daily dose of exercise, something many professional societies have been circling around for years. Clearly this study suggests it's more exercise than has often been cited.  We also wonder if prolonged exercise one day a week, such as Rick's cycling behavior, counts against the daily totals or if more or less daily exercise is needed.  No doubt more research coming, but for now, we agree, almost everyone needs to move more and sit less.

Other topics this week include two others from the Lancet on depression and behavioral activation therapy, and the global economic burden of inactivity, and in JAMA, the USPSTF's recommendations on skin cancer screening.  Until next week, y'all live well.

 

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iStock_26372146_MEDIUMIf you're a woman who's had breast cancer, you may be taking a class of drugs known as 'aromatase inhibitors' to help reduce your risk of a a recurrence. Most women are recommended to take these medications for five years either following drug therapy with tamoxifen, or as initial therapy.  In either case, is there a benefit to continuing aromatase inhibitors for another five years?  That's the substance of a study Rick and I discuss on PodMed this week, as published in the New England Journal of Medicine. And the good news is, yes, there is additional benefit.  What exactly did the study do?

Over 1900 postmenopausal women with early stage, hormone receptor positive breast cancer were enrolled in this trial. Median follow-up was 6.3 years. Women usually entered the study after having received tamoxifen following their diagnosis of early breast cancer for five years, followed by an aromatase inhibitor for around five years.  They were then randomized to an additional five years on an aromatase inhibitor or to placebo.  Results indicated that 95% of women on the aromatase inhibitor were disease free at five years compared with 91% of those on placebo. More women developed breast cancer in the other breast in the placebo group than in the group taking the aromatase inhibitor. While those on the active drug did experience more bone pain, new onset osteoporosis, and bone fractures, Rick and I agree that the reduction in risk for breast cancer recurrence seems worth it, and that's good news.

Other studies this week include an analysis of the Mediterranean diet in Annals of Internal Medicine, risk of breast cancer following IVF in JAMA, and in Neurology, a look at whether HRT improves cognition.  Until next week, y'all live well.

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iStock_21783395_MEDIUMIf you have knee osteoarthritis, you've probably noticed for sale in pharmacies and elsewhere some rather ugly footwear purported to alleviate pain, and perhaps you've considered such a purchase.  Now, as Rick and I discuss on PodMed this week, there's finally evidence, as published in Annals of Internal Medicine, that you can give such a strategy a miss.  Here's what the investigators did:

A total of 164 people with knee osteoarthritis were randomized to wear shoes designed to unload their medial knee, the area where most people experience degeneration and pain, or to conventional walking shoes. They were instructed to wear the shoes daily and then were followed for six months.  At the end of the intervention period they were queried with regard to pain with walking and physical function. A number of secondary outcomes included knee stiffness, intermittent and/or constant knee pain, and quality of life. One hundred sixty subjects completed the trial.  And, as Rick and I quip in the podcast, it's time to boot those ugly shoes to the curb, as there was no significant difference between the groups on any measurement.  Rick and I agree that this study is especially helpful because there are a lot of devices being sold to help people manage common conditions like osteoarthritis that have never been scrutinized carefully, and we're hoping this is just the first study to do so.

Other topics this week include two from JAMA on HIV management, and one from the Lancet on mortality and obesity.  Until next week, y'all live well.

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iStock_84620773_MEDIUMShould physicians assist people who wish to end their lives? Whatever your view on that matter, a study Rick and I discuss on PodMed this week attempts to quantify just how much euthanasia, where the physician administers drugs to end life, or the patient does so with drugs a physician has prescribed, so-called physician assisted suicide (PAS), takes place currently in places where the practice is legal.  That's published in JAMA.

This rather exhaustive study took a look at the five countries where euthanasia and PAS is legal: Canada, the Netherlands, Belgium, Luxembourg, Colombia, and the five US states where PAS but not euthanasia are legal: Oregon, Montana, California, Vermont, and Washington. Survey data beginning in 1947 was examined through 2015, as was data from death certificates and locations with reporting requirements relative to these practices.  Briefly, the study found that while the practice is being legalized more and more, rates of actual utilization remain about the same.  There is no evidence that vulnerable populations are being targeted, and the group that seems to utilize the practice most often are people with cancer.

Of surprise to both Rick and me, pain was not the primary reason cited by people who chose to end their lives, but rather a wish to die with dignity, having experienced a loss of autonomy and ability to enjoy life. The majority of people who make this election are educated, white, and older. In short, we feel the study does not support the idea that somehow legalizing the practice would expand its use, perhaps to those who haven't chosen to die themselves.

Other topics this week include two studies we treated as one on breast cancer trials in NEJM, staph infections in families in Annals of Internal Medicine, and an IOM report on biomarkers.  Until next week, y'all live well.

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iStock_000056500374_MediumThere's been a lot of emphasis in recent years on making sure that people with cancer get good end-of-life care, and that often involves consults with palliative care experts, referral to hospice and other strategies, but how do folks with other critical illnesses fare?  That's the substance of a study Rick and I discuss on PodMed this week, as published in JAMA Internal Medicine, with the primary finding that those with frailty, COPD, congestive heart failure and end stage renal disease (ESRD) don't receive these services nearly as often as those with cancer or dementia.  And there's room for improvement in cancer and dementia care also.

The records of almost 58,000 people who died while receiving care in  Veterans Administration facilities between October 1, 2009, and September 30, 2012 were examined.  About half of those patients with frailty, COPD, congestive heart failure, or ESRD had a palliative care consult while almost 74% of those with cancer did.  Among those with dementia just over 61% did so.

What about deaths in the ICU?  More than twice as many people without cancer or dementia died in this setting.  Finally, loved ones of those who died rated their care as excellent at the end of life more often for those with cancer or dementia, a measure that the authors say was mediated by do-not-resuscitate orders, palliative care consults, and setting of death. Rick and I agree that there's lots of room for improvement here, with education for providers as well as patients important in shifting perception of palliative care from end-of-life issues to enabling people to live as best they can with symptom control.

Other topics this week are all in Annals of Internal Medicine: coprescription of opioids and naloxone, treatment of binge eating disorder, and the relationship of dementia to blood transfusions.  Until next week, y'all live well.

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iStock_84561969_XXXLARGEAtrial fibrillation is a condition where the upper chambers of our four-chambered heart don't beat together with other heart areas, and this can allow blood clots to form and travel to the brain, causing a stroke.  Now, as Rick and I discuss on PodMed this week, so-called 'novel anticoagulants' have been shown to be as safe and effective at managing this condition as the tried and true warfarin, a study in the BMJ concludes.

The study is compelling because it followed almost 62,000 Danish citizens who were new to using oral medications to thin their blood.  The stalwart warfarin and three upstart novel anticoagulants or NOACs, as those in the know abbreviate, were all used among this cohort.  The NOACs were dabigatran, rivaroxaban and apixaban. Data was collected between August 2011 to October 2015. Briefly, the NOACs were just as good at preventing stroke and in some cases better at avoiding blood clots.  As Rick opines in the podcast, this information should be weighed along with other aspects of treatment with NOACs to assist patients in making an informed decision.  On the plus side, there's no need to monitor to what degree blood is being thinned as there is with warfarin, requiring a regular trip to the clinic some patients find very onerous. On the other hand, there's the ability to reverse warfarin effects readily if surgery is needed.  Then there's the cost issue.  What's not at issue is the importance of employing some strategy to reduce risk in people with atrial fibrillation, so it's good to be able to make informed choices.

Other topics this week include sudden cardiac death among youth in NEJM, and two in JAMA: plant phytoestrogens for menopausal symptoms and dietary consumption trends among US adults.  Until next week, y'all live well.

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iStock_84600825_MEDIUMIf you're someone who consumes a lot of pale foods- think white bread, refined rice, pasta made traditionally, it may be time to rethink your practice, as well as put some pressure on your favorite purveyors of fast food to do the same.  A study Rick and I discuss on PodMed this week, published in Circulation, as well as another published in the BMJ we don't highlight, provide some real data behind the assertion that whole grains may extend life.  Here's what the Circulation study did:  a meta-analysis of 14 eligible studies prospectively examining mortality and while grain consumption, representing in total almost 800,000 individuals.

Over the course of the collective studies, almost 100,000 deaths occurred, including about 24,000 from cardiovascular disease, and 38,000 from cancer. In crunching the numbers relative to whole grain intake, those folks who consumed the most had the least risk of dying, with a dose-response relationship evident and the most robust relationship with respect to cardiovascular disease death reduction. As Rick opines in the podcast, if medicine purveyed a pill that would reduce one's risk by the same amount that whole grain consumption does, people would be lining up to take it.  Brown rice, anyone?

Other studies this week include two from NEJM: changes in primary care instituted by CMS and their impact, as well as a medication for management of kidney disease in those with type 2 diabetes with regard to cardiovascular outcomes, and a comparison of weight loss drugs in JAMA.  Until next week, y'all live well.

 

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iStock_21807349_MEDIUMIf you eat less, even if you're of normal weight, you'll live longer, many researchers conclude from studies on monkeys and other animals.  Now, as Rick and I discuss on PodMed this week, a study in JAMA Internal Medicine demonstrates that calorie restriction improves a number of other quality of life factors, and Rick reveals he's already adopted the behavior!  What gives?

This study, known by the acronym CALERIE 2, randomized 220 men and women with a normal BMI to 2 years of 25% calorie reduction or consumption per usual.  Outcome measures utilizing self-administered questionnaires included mood, depression, quality of life, perceived stress, sleep quality and sexual function. At the end of two years, compared with the consumption as usual group, the calorie restricted group reported better mood, reduced tension, improved general health, improved sex drive and relationship, and improved sleep! There was a positive correlation with greater weight loss. Well. Seems like even if you don't live longer you'll live better by voluntarily restricting your food intake, and as Rick quips in the podcast, so will your partner.  Or should I say pardner. And we also discuss previous research that demonstrates decreased inflammatory markers, so sounds like such a choice may be a win-win.

Other topics this week include obesity trends and USPSTF recommendations for syphilis screening in JAMA,  and a look at the Mediterranean diet, weight gain and fat distribution in the Lancet.  Until next week, y'all live well.

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iStock_000063632745_MediumSuicide rates are increasing nationally, and they're also increasing among soldiers in the US Army. Now a study in JAMA Psychiatry Rick and I discuss on PodMed this week attempts to take a look at the multitude of factors that surround a suicide attempt in an Army enlistee, clearly with an eye toward intervention at risky times.  What did they find?

Records of regular Army soldiers from 2004 to 2009 were examined, and 9650 suicide attempts were identified. Here's what investigators found: "risk estimates for sociodemographic and mental health predictors were highest among those never deployed, and currently and previously deployed soldiers had the highest risk of attempt by firearm. Risk was highest in the second month of service (never deployed), sixth month of deployment (currently deployed), and fifth month after return (previously deployed)." A few other findings worth noting: women were more likely to attempt suicide, as were those whose Army career spanned two years or less, and both depression and post traumatic stress disorder were risk factors.   Rick and I agree that figuring out who is at risk and conducting targeted screening among those who fit the profiles might help bring down the rising rate of suicide among those in the Army, which has exceeded that in the general population beginning in 2008. We hope that such studies might also inform effective screening strategies that might be employed among the civilian population as well.

Other topics this week include Zika and microcephaly modeling in NEJM, and in Annals of Internal Medicine, public reporting of mortality data and the impact of improving HIV control in South Africa.  Until next week, y'all live well.

 

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iStock_000065162681_MediumBariatric surgery, or obesity surgery, is now being recommended for many people with type 2 diabetes (T2D), and thus should undergo a name change: metabolic surgery, as Rick and I report on PodMed this week.  That's according to a rather large consensus of 48 professional organizations, including the American Diabetes Association, and published in Diabetes Care.

There are 11 studies published in this issue of the journal and reviewed in the development of the guidelines that address various aspects of metabolic surgery, including the several types of operations available, people in whom they are indicated, and the role of diet and exercise. The authors assert that they are not advocating that surgery should be a first step in managing diabetes, but rather that some procedure is indicated in those with a BMI greater than 40 or those with a BMI of 35 or more and whose diabetes isn't managed well with other methods.

Of note to Rick and me is the cost-effectiveness aspect of metabolic surgery in managing T2D and therefore avoiding many of the complications of the condition.  This is especially interesting given that such an expansion of metabolic surgery as proposed in these guidelines would present a huge up front cost to the health care system.

Other topics this week include two from JAMA: management of hypertension in the elderly and sodium in those with chronic kidney disease, and in the Journal of Clinical Oncology, a look at what people with advanced cancer hear from physicians about their condition. Until next week, y'all live well.

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