iStock_27891038_MEDIUMHutterites have been figuring large in the medical research lately, with PodMed two weeks ago featuring a study on asthma and allergy in children in this community, while this week on the podcast Rick and I talk about a study comparing intramuscular flu vaccine to intranasal vaccine in two groups of these folks, as published in Annals of Internal Medicine. So we extend our thanks to the Hutterite people for agreeing to be a part of studies that advance knowledge for us all, in this case relative to flu vaccination methods.

The study was conducted over three influenza seasons among 52 Hutterite colonies in Alberta and Saskatchewan, Canada. Almost 1200 children ranging in age from 36 months to 15 years received a vaccine, while just over 3400 community members did not.  The study was designed to assess whether the live intranasal vaccine was superior to the inactivated intramuscular vaccine in providing protection for both the community (herd immunity) as well as the children.

Children were randomized to either the live attenuated intranasal flu vaccine against three strains of influenza, or to an inactivated vaccine containing the same three strains. About three quarters of the children in each group received the vaccine. There was no difference in the rate of influenza infection among either those vaccinated or persons in their community, with the authors concluding that there was no advantage to the intranasal live attenuated vaccine with regard to community protection.

I point out to Rick in the podcast however, that it also appears that the vaccine, marketed as FluMist, did work as well as the intramuscular vaccine, and may call into question the CDC's action of late June panning the intranasal vaccine for the upcoming flu season.  While I really did not like the one administration of this vaccine I received I am sympathetic to children who really don't like injections at all.  Time will tell, I suppose, on whether intranasal vaccines will return to favor.

Other topics this week include scrutiny of beta blocker use in those who've had stents in the Journal of the American College of Cardiology, a new osteoporosis drug in JAMA, and an association between Tylenol use during pregnancy and behavior problems in offspring.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_17258462_MEDIUMCan receiving text messages help improve a person's choices relative to reducing diabetes risk behaviors?  That was the central question addressed by a study Rick and I discuss on PodMed this week, as published in a journal we've never talked about before: the Journal of Medical Internet Research.  We're betting we will be hearing more from this journal as all over the world, the potential for using internet and mobile technologies to monitor, support and change choices that affect an individual's health is being undertaken, especially if the results equal or surpass those seen here.

This study was conducted in India among a cohort culled from a million Nokia phone subscribers. The study subjects received 56 text messages over the course of six months in their choice of 12 languages. The messages targeted fruit, vegetable and fat consumption and endorsed more exercise. A control group received no messages.  At the end of the study message receivers were more likely to consume more fruits and vegetables and attempt to reduce fat intake, although there was no improvement in exercise. The authors conclude that in low and middle-income countries, where diabetes risk is quite high and so is mobile phone access, such a strategy could have a great impact on new cases of diabetes in the future.  Questions we'd like to see answered would include the impact over a longer period of follow-up and the durability of results, but for now, we're encouraged.

Other topics this week include the impact of exercise on five common health conditions in the BMJ, ICU stays versus those on a medical floor with regard to outcomes in JAMA Internal Medicine, and insurance status and outcomes for two cancers in Cancer.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_6759635_MEDIUMWhat can Amish and Hutterite people teach us about genes, the environment, and the development of asthma?  Lots, according to a study Rick and I discuss on PodMed this week and published in the New England Journal of Medicine. This study looked at two groups of people who originally emigrated to the US from geographically similar central European areas and share the majority of their genes. They ultimately settled in two different farming communities in Indiana and South Dakota, respectively, and their farming practices are also distinct.  The Amish have generally small, family run operations while the Hutterites tend to work large corporate farms, thus their exposures are quite different.

It turns out the prevalence of asthma among the Amish children is just over 5% while  over 21% of the Hutterite children develop the condition.  Allergic sensitization is also divergent: 7.2% in the Amish versus 33.3% in the Hutterites.  By employing a mouse model, this study was able to demonstrate that dust from Amish homes inhibited airway reactivity and cellular proliferation characteristic of allergy. Researchers conclude that early and presumably sustained exposure to this allergen mix engages the innate immune response that is ultimately protective against asthma and allergy. Rick and I agree that precise identification of the allergens as well as timing of exposure may provide a likely therapeutic strategy to prevent asthma.

Other topics this week include a look at obesity, diabetes and cardiovascular events among a group of identical twins with divergent weights in JAMA Internal Medicine, off site cardiac monitoring in at risk patients in JAMA, and in MMWR, a look at preparedness nationally for preventing Zika-related fetal abnormalities.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

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.

 

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

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.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

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.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

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.

VN:F [1.9.17_1161]
Rating: 5.0/5 (1 vote cast)
No Comments

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.

VN:F [1.9.17_1161]
Rating: 5.0/5 (1 vote cast)
No Comments

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.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

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.

 

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments