iStock_000044075022_MediumPlacing a tablet with an allergen under someone's tongue to help ameliorate allergic responses has been around for a bit and is known as 'sublingual immunotherapy', but now, as Rick and I discuss on PodMed this week, the strategy was tried in people with moderate to severe asthma who were allergic to dust mites to try to reduce asthma attacks or exacerbations when corticosteroids were tapered.  Wow, that's a mouthful in describing the study population, but the upshot is it is desirable both to reduce corticosteroid use in these folks but also to avoid hospitalizations relative to asthma attacks. The study was published in JAMA, and the news is good. The two groups who received the allergen under their tongues did see a reduction in their exacerbations even when the steroids were reduced and discontinued.

Rick says the benefits to the treatment, abbreviated 'SLIT,' are multiple, and include ease of administration (no one likes shots!) and a reduced dosing schedule over months rather than continuously, as is seen with allergy shots.  Potential downsides include slightly less efficacy relative to injections and some oral itching and associated mouth symptoms in about 20% of the higher dose SLIT group. Do these results warrant expanded investigation into other groups of allergic folks, and perhaps tablets with more than one allergen?  Stay tuned, as we agree that the likelihood seems high.

Other topics this week include 'antibiotic stewardship' and risks of smoking cessation drugs in the Lancet, and methods to reduce Clostridium difficile infection in the hospital in JAMA Internal Medicine. Until next week, y'all live well.

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iStock_000062391332_MediumPeople who have greater economic resources live longer than those who don't, a study published in JAMA that Rick and I discuss on PodMed concludes. This conclusion is certainly rather sobering and is bolstered by a very large amount of data: "Income data for the US population were obtained from 1.4 billion deidentified tax records between 1999 and 2014. Mortality data were obtained from Social Security Administration death records. These data were used to estimate race- and ethnicity-adjusted life expectancy at 40 years of age by household income percentile, sex, and geographic area, and to evaluate factors associated with differences in life expectancy."  Wow.  Rick and I are both impressed and daunted by the shear size of this dataset. Watson, anyone?

The study essentially found that there is a more or less positive relationship between income and longevity, with those who make the most money living longest. This is a trend that is increasing over time, accounts for a greater disparity in the lifetimes of men than women, and varies quite a bit across the nation's geography.  Perhaps most interesting is the fact that access to healthcare did not seem to affect longevity.  The factors that were associated with shortened lifetime included smoking, sedentary lifestyle and poor dietary choices.  We agree that there is ripe fodder for policy change in these conclusions and suspect that's where this study will have the most impact.

Other topics this week include a long term look at the high end of normal BMI and cardiovascular mortality in NEJM, five star ratings of hospitals in JAMA Internal Medicine, and aspirin recommendations in Annals of Internal Medicine.  Until next week, y'all live well.

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iStock_000067787695_MediumWhen you think of Chinese food it's a likely bet you don't think of fresh fruit, as Rick quips on PodMed this week.  That's per a study we discuss in the New England Journal of Medicine on the impact of fresh fruit consumption among a very large cohort of Chinese people living in China on cardiovascular health. Here is the rather amazing description of the study population from the article: "Between 2004 and 2008, we recruited 512,891 adults, 30 to 79 years of age, from 10 diverse localities in China. During 3.2 million person-years of follow-up, 5173 deaths from cardiovascular disease, 2551 incident major coronary events (fatal or nonfatal), 14,579 ischemic strokes, and 3523 intracerebral hemorrhages were recorded among the 451,665 participants who did not have a history of cardiovascular disease or antihypertensive treatments at baseline." Wow. That's a lot of follow up.  The researchers discerned an inverse relationship between fresh fruit consumption and cardiovascular events, even though those folks who consumed more fruit also had higher BMIs and greater central obesity.  Paradoxical much?

It's tempting to simply ascribe the benefits of fruit as protective as so many studies have concluded with regard to fresh foods, but Rick also points out that the Chinese diet is very high in vegetables, actually much higher than most Western diets, seeming to indicate a fruit specific effect.  I speculate that just as we see a salt sensitivity with regard to hypertension in those of African descent, maybe there's something about Asian ethnicity that makes the fruit factor important.  In any case, perhaps we're going to see more fresh fruits on the menu in Chinese restaurants. Other topics this week include atrial fibrillation after cardiac surgery and statins for intermediate risk people, also in NEJM, and in JAMA, recommendations from the USPSTF on screening for COPD.  Until next week, y'all live well.

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iStock_000056500374_MediumWhen people choose to leave the hospital near the end of life, do they die more quickly than those who elect to stay?  Rick and I discuss this study on PodMed this week, as published in Cancer, and were both informed and pleased to learn that those who go home live longer in the short term, over days and weeks, than those who remain hospitalized, while those with a life expectancy of a few months live about the same length of time.  Our hope is that this study will relieve the burden of guilt experienced by some family members and loved ones that someone isn't receiving the very best care and may die more quickly at home.

Just over 2000 patients were enrolled in this study, conducted at 58 palliative care practices in Japan. Here's the data: A total of 1607 patients actually died in a hospital, and 462 patients died at home. The survival of patients who died at home was significantly longer than the survival of patients who died in a hospital in the days’ prognosis group (estimated median survival time, 13 days [95% confidence interval (CI), 10.3-15.7 days] vs 9 days [95% CI, 8.0-10.0 days]; P5.006) and in the
weeks’ prognosis group (36 days [95% CI, 29.9-42.1 days] vs 29 days [95% CI, 26.5-31.5 days]; P5.007) as defined by Prognosis in Palliative Care Study predictor model A. No significant difference was identified in the months’ prognosis group. Since most people identify their preference as dying at home, this study should support both patients and their loved ones in making such a decision.

Other topics this week include cardiac interventions following cardiac assessment prior to surgery in JAMA Internal Medicine, and two from NEJM: HRT timing and Lyme disease and long term antibiotic use.  Until next week, y'all live well.

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iStock_000059837422_MediumLow back pain is both chronic and debilitating in many people, and methods to alleviate it have often proven disappointing.  Now comes a study in JAMA Rick and I discuss on PodMed this week suggesting that both CBT, cognitive behavioral therapy, and MBSR, the authors'  acronym for 'mindfulness-based stress reduction,' are equally effective at helping those with the condition manage it.  And btw, that's significantly effective, reducing pain 'bothersomeness' by almost 50% in those who underwent either CBT or MBSR, compared with almost a 27% reduction in those who received usual care.

This study was impressively long term as well: 342 participants were randomized to one of the three treatments.  They ranged in age from 20 to 70 years, and some of them had been struggling with low back pain for fifty years!  After a treatment period of 8 weekly group sessions lasting two hours or usual care, the subjects were followed for a year. Almost 85% of the entire group completed the study, and the benefits of CBT and MBSR persisted at the 6 month interval.  At one year the MBSR effects were about the same as the six month interval.  Rick suggests that perhaps the ability of those who were in this arm of the study to practice both yoga and meditation at home, with the help of a study-provided CD, may account for this outcome. In any case it seems clear that such interventions are worth attempting, especially in light of recent CDC guidelines on prescription of opioid medications for pain.

Other topics this week include two techniques for ventilator weaning following abdominal surgery, also in JAMA, the best time to introduce parenteral nutrition in critically ill children in NEJM, and use of complementary and alternative medicines and how often allopathic physicians hear about that in JAMA Internal Medicine.  Until next week, y'all live well.

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iStock_000062038310_MediumIf you're attempting to quit smoking, turns out the best way is simply to do so "cold turkey" rather than attempt a gradual cessation approach. That's according to a study Rick and I discuss on PodMed this week, as published in Annals of Internal Medicine. Both short- and long-term success rates were better in those who chose a date to quit and then did so compared to those who tried to cut down over time, with both groups receiving pychosocial support and nicotine replacement.

Almost 700 adult smokers were enrolled in this trial from primary care clinics in England. Subjects either quit abruptly or gradually reduced their smoking behavior over two weeks before a stop date. Here's the data:

The primary outcome measure was prolonged validated abstinence from smoking 4 weeks after quit day. The secondary outcome was prolonged, validated, 6-month abstinence.

Results: At 4 weeks, 39.2% (95% CI, 34.0% to 44.4%) of the participants in the gradual-cessation group were abstinent compared with 49.0% (CI, 43.8% to 54.2%) in the abrupt-cessation group (relative risk, 0.80 [CI, 0.66 to 0.93]). At 6 months, 15.5% (CI, 12.0% to 19.7%) of the participants in the gradual-cessation group were abstinent compared with 22.0% (CI, 18.0% to 26.6%) in the abrupt-cessation group (relative risk, 0.71 [CI, 0.46 to 0.91]). Participants who preferred gradual cessation were significantly less likely to be abstinent at 4 weeks than those who preferred abrupt cessation (38.3% vs 52.2%; P = 0.007).

Rick and I agree that this study adds to our burgeoning knowledge on how best to support people who desire to quit smoking. Of course I opine that this is all very well until we outlaw the things but that's another story. Other topics this week include a failure of genetic assessment to change behavior in the BMJ, vaccination and subsequent disease in JAMA, and safer prescribing in NEJM.  Until next week, y'all live well.

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iStock_000022086164_MediumWhat in the world is an ultraprocessed food and what does it have to do with your health?  Lots, a study in the BMJ asserts, and Rick and I agree on PodMed this week.  Let's start first with their definition: ‘ultraprocessed foods’ (formulations of several ingredients which, besides salt, sugar, oils and fats, include food substances not used in culinary preparations, in particular, flavours, colours, sweeteners, emulsifiers and other additives used to imitate sensorial qualities of unprocessed
or minimally processed foods and their culinary preparations or to disguise undesirable qualities of the final product).  Hmmm.  I simplify this to a foodstuff capable of surviving a nuclear blast unscathed, and we all know which foods those are, perhaps even having some of them in our very own kitchen cabinets, where they've resided for several years. Okay, what about the health risk? Turns out that NHANES data reveal that ultraprocessed foods comprise a whopping almost 60% of the average American diet, and provide us with 90% of our consumption of added sugars.  Since said sugars are linked in many studies to obesity and its host of nasty health consequences, as well as high blood pressure, stroke, coronary artery disease and the more pedestrian dental caries, the WHO recommends reducing consumption.  Et voila! Simply eliminate those ultraprocessed consumables and all will be well.  Rick and I would also like to thank the authors for expanding our vocabulary.

Other topics this week include long term results of peanut feeding to infants in NEJM, and a look at incompatible kidney recipients in the same journal. Finally, we example the obesity paradox in Annals of Internal Medicine.  Until next week, y'all live well.

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iStock_000055567080_MediumThe United States Preventive Services Task Force (USPSTF) has agreed that there is insufficient evidence to recommend vision screening for older adults in primary care settings, as published in JAMA.  Hmmm, Rick and I muse on PodMed this week.  We agreed that our a priori assumption would have been that of course, screening in such a place would  make sense: the primary tool is low-tech and easily administered, it has a high detection rate, and it doesn't cost much (a vision chart).  Yet after reviewing a plethora of studies the task force concluded that there just isn't enough research demonstrating benefit to go forward.  This against a backdrop of rather substantial burden of disease:

"In 2011, about 12% of US adults aged 65 to 74 years and 15% of those 75 years or older reported having problems seeing, even with glasses or contact lenses.1 The prevalence of AMD is 6.5% in adults older than 40 years and increases with age (2.8% in those aged 40-59 years and 13.4% in those aged ≥60 years).2About half of all cases of bilateral low vision (ie, best-corrected visual acuity of <20/40) in adults 40 years and older are caused by cataracts. The prevalence of cataracts increases sharply with age; an estimated 50% of US adults 80 years or older have cataracts.1 The prevalence of hyperopia requiring a correction of +3.0 diopters or more ranges from about 5.9% in US adults aged 50 to 54 years, to 15.2% in adults aged 65 to 69 years, to 20.4% in adults 80 years or older.1"

Rick confides that clinically, he recommends all his patients have an eye exam yearly.  Yet I wonder what percentage of those patients actually act on that recommendation, especially if their vision compromise is invisible to them (sorry!)? We look forward to more study in the future.

Other topics this week include the relationship between Zika virus infection and Guillain-Barre syndrome in the Lancet, and two from NEJM: labor induction in older first-time moms, and long term survival among those who've experienced a childhood cancer.  Until next week, y'all live well.

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iStock_000086115007_MediumShould you vaccinate your early adolescent children for HPV, or human papilloma virus?  The answer has been yes for some time, but now, as Rick and I discuss on PodMed this week, a study in Pediatrics has shown convincingly that young women who are vaccinated experience far fewer HPV infections than those who aren't vaccinated, and that translates down the road into fewer precancerous lesions and frank cancers of the cervix.

Researchers crunched data from NHANES, that nationally representative, ongoing study of many of our health habits, and found that the rate of infection with HPV dropped by 64% in young women 14 to 19 years of age. The drop was seen in the 4 specific types of HPV covered with the vaccine but not in other common types. Rates of infection among older cohorts with less vaccine coverage experienced commensurate drops. Rick and I agree that this is proof positive that the vaccine eliminated infection with HPV, which is known to cause cancer.  Clearly those parents who'd like to prevent cancer in their children, boys as well as girls, should have their children vaccinated.  Now the HPV vaccine provides coverage against 9 types of the virus so is even more effective in preventing cancers.  No more excuses, we say.

Other topics this week include a step down in ovarian cancer treatment and discontinuing aspirin before cardiovascular surgery in NEJM, and how acute respiratory distress syndrome or ARDS is managed worldwide in JAMA.  Until next week, y'all live well.

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iStock_000002132182_MediumIn our seemingly endless quest for eternal youth, testosterone supplements have occupied a place for older men, but do they really have any impact?  That's the subject of a study in NEJM Rick and I talk about on PodMed this week, and the results don't make a compelling case to use the stuff, in this case, testosterone gel.  What did they do in the study?

A total of 790 men with a serum testosterone measurement of less than 275 ng/dl were randomly assigned to either daily testosterone gel or a placebo gel for one year, with the objective of keeping testosterone levels in the midrange of normal for men 19 to 40 years old in those who received the testosterone. All of the men were 65 years of age or older, and none had health conditions that would contraindicate use of testosterone.  It's worth noting, as we do in the podcast, that finding that number of men among those screened was like the proverbial needle in a haystack: over 51,000 men were screened to yield this relatively small number with established low testosterone levels. Among the men who were on the testosterone gel in this study, they did report improved sexual activity, including improved desire and erectile function. Effect sizes were low to moderate, as they were for some measures of physical function and mood.  There were no adverse cardiovascular events but we wonder if the trial continued longer if some might emerge.  In sum, seems like men who have established low testosterone levels might choose to use the gel if their sexual function was very important to them.

Other topics this week, all from NEJM, include Ebola virus management in the US and Europe, use of pioglitazone in folks who've had a stroke, and a look at carotid endarterectomy or stent placement in people with carotid stenosis but without symptoms.  Until next week, y'all live well.

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