iStock_000048350132_MediumAre e-cigarettes the greatest thing since sliced bread or a machination of the devil?  The rancorous debate roils on, with studies abounding, as Rick and I discuss on PodMed this week.  Now comes a study in JAMA that seems to supports the latter assertion, at least for teenagers.  The study followed just over 2500 9th grade students from several California high schools, all of whom reported never having used a combustible tobacco product (note new terminology, cognoscenti) at the time of recruitment. The students were assessed at baseline, at six months, and then at 12 months of follow-up for e-cigarette and combustible cigarette use. In summary, those who reported e-cigarette use were more likely than those who didn't use the devices to begin combustible tobacco product use over the year of follow-up.  The finding suggests that e-cigarettes are a means to addict people to nicotine use and promote a transition to frank smoking.  As Rick opines in the podcast, this is troubling because teenagers are a vulnerable population, with developing brains that are susceptible to nicotine as well as other psychoactive substances.  We agree that regulation of e-cigarettes as well as traditional cigarettes should include prohibition of sales and use in those younger than 21 years of age.

Other topics this week include a genetic basis for different types of fat in our bodies, with implications for obesity in NEJM, the impact of being part of a military family on children, and liraglutide for managing weight in people with type 2 diabetes in JAMA.  Until next week,y'all live well.

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iStock_000012783948_MediumButter lovers, rejoice!  A study Rick and I discuss on PodMed this week and as published in the British Medical Journal once again comes to the conclusion that when it comes to cardiovascular risk relative to the development of atherosclerosis, saturated fats are not the culprit, but that human invention, trans fats, are. In point of fact this meta-analysis went further than that, assessing 12 studies with regard to all cause mortality, cardiovascular disease mortality, coronary heart disease, ischemic stroke, type 2 diabetes and consumption of saturated and trans fats.  Yikes.  That's a lot of data parsing! In short, the study concludes that consumption of saturated fats was not associated with any of the outcomes identified above, but consumption of trans fats were associated with all cause mortality and coronary heart disease morbidity and mortality.

Trans fats, as I suggest in the podcast, were developed for a number of reasons, among them the idea that saturated fats were involved in the deposition of plaques within arteries known as atherosclerosis.  But surprise!  Turns out when we mess with nature and produce chemical bonds in places they don't normally occur, so called 'trans fats', these are actually worse from an atherosclerotic viewpoint.  So leave that margarine alone, I say, and enjoy your butter, chocolate, nuts and other sources of saturated fat, but don't go overboard.  The majority of what you consume should still be vegetables and fruits, in a form as close to nature as possible.  And don't forget the postprandial walk.

Other topics this week include cardiac troponin significance in people with diabetes in NEJM, fresh versus frozen oocytes in JAMA, and testosterone supplements and atherosclerosis in men, in JAMA.  Until next week, y'all live well.

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iStock_000046130062_MediumAt long last, a vaccine has been developed and tested that provides virtually total protection from Ebola virus infection, a great news study published in the Lancet has shown. Yay! Rick and I rejoice on PodMed this week.  Seems like it's been a long time coming, with thousands of people dying in rather horrific ways.

The study used a " open-label, cluster-randomised ring vaccination trial" design, with almost 8000 subjects from among people presumed to be exposed to someone with frank, confirmed Ebola virus infection. Briefly, some of the contacts were vaccinated immediately after their presumed exposure while others were vaccinated 21 days later. Development of Ebola virus disease in immediate and delayed vaccination groups was assessed, revealing 100% efficacy for the vaccine in preventing disease in those vaccinated immediately. Next steps will of course expand vaccination efforts and hopefully Ebola will be simply a blip on the landscape until the next viral illness emerges.  Other topics this week include restoring Circadian rhythm in persons who are totally blind with an eye toward alleviating insomnia, also in the Lancet, in Lancet Oncology a reduction in endometrial cancer risk with oral contraceptives, and management of anticoagulation in people with atrial fibrillation who may need stents, in the JACC.  Until next week, y'all live well.

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iStock_000023037295_LargeKids are famous for putting things in their bodily orifices that subsequently require a visit to an ED to assess and remove.  Especially lately, batteries of the button variety seem to be in vogue.  Enter now, as Rick and I discuss on PodMed this week, an actual therapy involving placing a balloon in the nose of a child (!) as a treatment for fluid accumulation in the middle ear following an ear infection, or in the vernacular, middle ear effusion after acute otitis media.  The study is reported in the Canadian Medical Association Journal, and I'm guessing it's just a matter of time before this is the latest on the playground.  And just in time for back to school!

A total of 320 children aged 4-11 who had acute ear infections and effusion were randomized to the nasal balloon three times daily or usual care for a period of three months (!).  The children were amazingly compliant with treatment; at one month 89% were using the balloon as prescribed, and at three months 80% were doing so.  The strategy also resulted in about 12% greater likelihood of resolution of the effusion at both one and three months.  Sounds like a win-win to us.  Other topics this week include depression screening recommendations from the USPSTF, hypothermia for kidney graft donors, and a new treatment for elevated triglycerides, both in NEJM. Until next week, y'all live well.

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HiResThe profound impact of poverty on children has been chronicled in lots of studies, but this week Rick and I discuss on PodMed a study that looks at specific brain areas in kids raised in poverty and those raised without that barrier.  As published in JAMA Pediatrics, the sobering revelation is that in brain areas associated with learning readiness, including the frontal lobe, temporal lobe, and hippocampus, reduced gray matter was seen in those raised in poverty.

Brain composition was assessed using MRI scans from 301 participants in the NIH Magnetic Resonance Imaging Study of Normal Brain Development study. One-quarter of sample households reported their total family income below 200% of the federal poverty level, with the remainder spread across the income spectrum.  Educational attainment of parents was also assessed in this study, and perhaps most distressingly, at least for me, college and even graduate degrees of their parents offered no protection with regard to poverty or brain development for those children at the bottom of the income scale.  As I speculate with Rick in the podcast, seems like it should be fairly straightforward to find the smoking gun(s) and develop interventions to overcome this problem.  In our world of abundance, saddling children with such a disability at the very beginning of life is indefensible.

Other topics this week include the interaction of Coumadin with dicloxacillin in JAMA, bystander CPR (2) in the same journal, and likelihood of overcoming obesity in the American Journal of Public Health.  Until next week, y'all live well.

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iStock_000012753279_FullCould one benefit of aging be taking fewer medications?  That outrageous idea may be the upshot of a study Rick and I discuss on PodMed this week, as published in JAMA, taking a look at appropriate management of high blood pressure in those aged 80 and older. The study aggregated six post hoc analyses of data from the Hypertension in the Very Elderly Trial, conducted in almost 4000 hypertensive subjects over the age of 80. The analysis concludes that for older folks who are generally healthy and functional, high blood pressure should be managed according to the guidelines for those older than 65, with positive impact on outcome measures such as total mortality and cardiovascular events.  A target systolic blood pressure of 140-150 should be employed, and one or two medications at most, relieving many of the burden of polypharmacy, or at least reducing it. For those who are frail, and already taking a multitude of medications for other conditions, hypertension management should be conservative at best, with that catch all phrase 'individualized treatment' used.

No doubt for many older folks, this relaxation of blood pressure targets will come as a relief, and underscores observations we've made before: as we age our physiology changes, and reasonable accommodation should be made.  Other topics this week include the cost and effectiveness of cholesterol guidelines and a new drug for high potassium, also in JAMA, and in NEJM, a snapshot of community acquired pneumonia.  Until next week, y'all live well.

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iStock_000044730596_Full (1)No one wants to have shots, but they're especially problematic in children.  Welcome then was the news a few years back that a simple tablet placed under the tongue could induce enough tolerance that many children with allergies might forgo allergy shots altogether.  Alas, as Rick and I discuss on PodMed this week, it appears the early results haven't been borne out, at least according to a meta-analysis in JAMA Internal Medicine.

Data was pooled from over 4500 patients in whom sublingual immunotherapy utilizing tablets took place in a randomized controlled trial.  Outcome measures were symptom management and use of medications to control symptoms.  A very modest benefit of sublingual immunotherapy was seen in terms of reduction in symptoms or medication use, while over 60% of study subjects reported adverse events, compared with about 21% of the control population.  Well.  Rather disappointing, as I've already opined, but also calls into question the basis upon which the FDA approved sublingual immunotherapy in 2014.  At the very least calls for re-examination of the issue and perhaps a comparison with standard issue allergy shots.

Other topics this week include extended use of anticoagulation in folks who've had pulmonary embolism without a discernible cause, and continued cognitive decline after stroke, both in JAMA, as well as rates of healthcare workers coming to work while ill, in JAMA Pediatrics.  Until next week, y'all live well.

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iStock_000005928967_Double-120x86Melanoma is a frightening prospect for most, and the number of people who develop it seems to increase all the time.  Now, as Rick and I discuss on PodMed this week, comes a study suggesting that certain citrus fruits, and very specific forms of said fruits, increase the risk of developing this most deadly form of skin cancer.??????? what? These fruits touted as beneficial might actually be detrimental?  Let's take a bit of a closer look at this study published in the Journal of Clinical Oncology.

The study combines data from the Nurses Health Study and the Health Professionals Follow-Up Study for a total of more than 100,000 subjects.  Lots of data has been gathered over decades in these vigilant folks, including dietary questionnaires and objective information such as disease development.  The long and short of it in this analysis is a relationship between melanoma development and consumption of grapefruits, but not grapefruit juice, and a less robust relationship between orange juice and the disease, but not whole oranges.  Hmmmm.  Certainly gives pause for contemplation if nothing else, along with speculation on differences in forms and fruits in the citrus family.  Rick and I agree that action points for now are non-existent, unless you're a researcher with money to examine this relationship prospectively.  Garnered lots of media attention, however.

Other topics this week include the diabetes drug liraglutide for obesity in NEJM, stroke treatment guidelines in Stroke, and a vaccine for Helicobacter pylori in the Lancet.  Until next week, y'all live well.

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iStock_000042621248_LargeWith 23 US states and the District of Columbia already having legalized marijuana for medicinal use, Rick and I agree on PodMed this week that the horse is out of the barn with respect to its widespread utilization.  Yet we discuss two studies in JAMA this week examining the trials that have attempted to scrutinize the purported benefits of marijuana and are forced to agree with the editorialist that better trials are needed.  The primary study is a meta-analysis of all databases since inception to April 2015; rather dauntingly comprehensive, we agree! Studies included examined the benefits of medical marijuana for a variety of conditions ranging from side effects of chemotherapy to spasticity. Almost 6500 subjects comprised the study cohort.  In short, the authors found moderate quality evidence that marijuana was beneficial for chronic pain and spasticity, but low quality evidence supporting its use in the remainder of conditions examined.  Moreover, a significant risk of a range of side effects, ranging from dizziness to frank hallucination, was found. Sounds like a need for high quality studies to us.

Other topics this week, all from NEJM, include bridging anticoagulation for those with atrial fibrillation on blood thinners, an antibody to reverse the common anticoagulant dabigatran, and screening for cancer in those who present with unprovoked deep venous thrombosis.  Until next week, y'all live well.

Other topics this week include

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36138532_thumbnailSurgery for acute appendicitis is a time-honored tradition, immortalized in the children's classic 'Madeleine.' Now, however, a study in JAMA and one Rick and I highlight this week on PodMed suggests that a course of antibiotics can help the majority avoid surgery altogether, and for the approximately one-quarter who will need to go to the OR, there is no significant consequence to waiting.  Wow.  Clearly a practice-changing finding if ever we've seen one.  In a study that could only be done outside our litigious culture, Finnish researchers randomized over 500 patients with acute, uncomplicated appendicitis confirmed by CT to either immediate surgery, or "intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day)."  The trial was designed to assess non inferiority of the antibiotic treatment, and just failed to meet that standard of 76% of patients avoiding surgery.  It did, however, have the outcomes I mentioned already.  Rick and I opine that if we presented with acute, uncomplicated appendicitis we would definitely opt for the trial of antibiotics, but concede that some folks might prefer an immediate solution via surgery.  Clearly the study informs shared decision-making between caregiver and patient but will likely take a lot of time to penetrate care patterns domestically.

Other topics this week include pregnancy and lupus, seat belts and motor vehicle fatalities,both in Annals of Internal Medicine,  and knee arthroscopy outcomes in the BMJ. Until next week, y'all live well.

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