72991367Handoffs, or to wax PC, handovers, are those circumstances where the person who's been managing a patient during a particular time period in the hospital meets with those just coming on to the unit and recites what's been done, current status, medications and so on relative to the patient's care as they end their shift. As Rick and I discuss on PodMed this week, and as published in a study in JAMA Internal Medicine, this is prime time for medical errors, some of which could seriously compromise patient care.  And as Rick laments on the podcast, this problem has been recognized for some time in academic medicine but has so far proven quite resistant to attempted remedies.  What did they do here?

Investigators tagged along on morning handover in two tertiary care academic medical centers in Toronto, Canada, on the general internal medicine service. Medical care on these services is provided during the day by a team consisting of one attending physician, one senior resident, at least two interns, and two medical students. At night an on-call trainee provides care, and this is usually a member of the daytime team but may be a trainee from another service or team.  Electronic medical records are employed in both centers but notes by both physicians and nurses occur on paper. The verbal handover process is supported by an Internet-based written sign out tool.

The researcher took notes during morning handover and in particular the occurrence of interruptions or distractions during the process. Each case was reviewed by investigators and pertinent data and notes by care providers integrated. Data from 26 observations revealed that  "The on-call trainee did not verbally hand over 40.4% (95% CI, 32.3%-48.5%) of the clinically important overnight issues and did not document a progress note for 85.8% (95% CI, 80.1%-91.6%) of these issues. Trainees documented 7.8% (95% CI, 3.4%-12.2%) of clinically important issues in the Internet-based written sign-out tool. There were 52 (36.9%; 95% CI, 28.9%-44.8%) clinically important issues that were neither handed over nor documented by the on-call trainee."

Wow.  That's a lot of important information relevant to a patient's care that wasn't revealed in the handoff, and didn't appear elsewhere either. Factors that may have contributed include the following: "Handover took place in many different locations in the hospital  and occurred in a dedicated team room only 41% of the time. Teams divided the handover process into more than 1 encounter 68% of the time (eg, handover of overnight issues occurred before and after morning teaching rounds). Teams met for a mean total of 71 (26) minutes to review new cases and hand over overnight issues. Teams spent most of their time reviewing new information on patients admitted during the previous night, with a mean of only 11 (10) minutes dedicated to handing over on-call overnight issues. During these interactions, teams experienced 6.1 (7.1) distractions per hour resulting in 2.6 (2.9) interruptions per hour."  As Rick opines in the podcast, these findings point to clear ways to redesign the process to help minimize the errors, while I assert that this is clearly a place where family or loved ones can help support the team in providing care by also reviewing the chart, medications, tests and so forth.  Seems a likely place where substantial improvements can be made.

Other topics this week include catheter-based thrombolysis for deep vein thrombosis in the same journal, morcellation and uterine fibroids in JAMA, and a new pathway identified in antiphospholipid antibody syndrome in NEJM.  Until next week, y'all live well.

 

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481422389Electronically based interventions in clinical care have thus far proven somewhat disappointing, as Rick and I have discussed on PodMed many times, but this week, we talk about a study utilizing electronic devices, telephone or Internet interface, and nurses to help people manage their chronic pain. The results, reported in JAMA, appear very encouraging.  Here's what they did:

Two hundred fifty people with chronic pain of at least three months duration were randomized to either usual care, administered by a physician, to manage their pain, or to automated symptom monitoring either by phone or Internet, weekly for one month, followed by every other month for months 2 and 3, and then monthly for months 4 through 12.  Subjects answered 23 questions to assess pain level, anxiety level, depression, the degree to which pain was disabling, whether current medications were being taken as prescribed and how well they were working, and whether a call with a nurse was needed.

The study utilized a stepped care analgesic optimization algorithm developed on a review of the literature relative to pharmacologic management of pain. 6 classes of analgesics were employed, ranging from acetaminophen and NSAIDs to opioids. Adjustments in type or dose of analgesic were determined by the nurse and prescribed by a study physician in the intervention group  if the subject requested a change, less than 30% improvement in the overall pain score was seen, or global improvement was not at least moderate. The control group was managed by their primary care physician.

All study participants had pain of musculoskeletal origin. People in the intervention group had greater improvement in their pain control and reductions in pain severity than the usual care group, and these results did not differ by age, gender, education level, race or socioeconomic status.  There was no difference between the telephone and Internet interface groups. Finally, when we cite that current favorite in the medical literature, number needed to treat, we see a very modest 4:1 ratio, indicating that 4 patients must be treated for one to improve significantly.  That's pretty good, considering the fact that we routinely advocate for treatments and interventions with much higher numbers, and that the intervention is inexpensive, and convenient for both patient and provider.

How about that other hot button issue right now, opioid use? Although one-third of all subjects were taking these medications at the start of the study, very few people in either group started opioids for the first time or increased their dose during the study period.  The authors opine that the systematic approach to pain assessment and medication use utilized in this study helps, and that the addition of other strategies such as cognitive behavioral therapy might further improve these results. Since pain is the most commonly reported symptom in the general population, getting our arms around best care practices is crucial.

Other topics this week include two on stroke in JAMA, pill changes and compliance in Annals of Internal Medicine, and niacin for the prevention of cardiovascular disease in NEJM.  Until next week, y'all live well.

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470639625Carotid artery stenosis.  Well, if there was ever a bit of medicalese this is it. So let's dissect the term, as Rick and I do on PodMed this week, so we can further dissect new recommendations of the United States Preventive Services Task Force or USPSTF published in Annals of Internal Medicine regarding the condition.

The carotid artery is the major blood vessel carrying blood to your head, including that critical structure: your brain.  You have two of these arteries that pass upward on either side of your neck and then divide into internal and external carotid arteries, where they may dive deep into the brain itself or supply the face, respectively. As you can feel on your own by placing your fingers on the side of your neck and feeling for your pulse, this is a sizable vessel with a big job.  So if/when blockages start to impede the flow of blood through the carotid, so-called 'stenosis' or narrowing, the consequences can be dire. Enter then the strategy of screening for carotid artery stenosis, employed some years ago now by simply listening, with a stethoscope, to blood roiling around in the artery.  This is underpinned by ultrasound examination of the artery, with both of these techniques having the advantage of being quick, inexpensive, noninvasive, and painless.  Sounds great, huh?  But does screening people who don't have symptoms result in less stroke, the aforementioned dire potential consequence of carotid artery stenosis? And once identified, does treating narrowing of the vessel really help reduce the risk of stroke or result in other deleterious consequences of treatment?

As Rick would say, that was the subject of this USPSTF guideline, based on examination of all the evidence relative to screening asymptomatic people, possibly treating them, and their subsequent risk for stroke on the same side of the body in which stenosis was identified? In short, the evidence argues against screening at all, in view of the chance that such screening will result in treatment and its host of potential side effects, none of them good.  To begin with, the use of ultrasound to screen in a population in whom the prevalence of the condition is low results in a very large number of false positive results. A perioperative stroke or death rate of less than 3% was seen in this analysis when carotid enarterectomy to remove plaque inside the artery was employed, but the authors state that observational trial results are much higher.  Finally, in comparison to medical therapy surgery is no longer emerging as the superior choice.  To sum then, in people without symptoms looks like screening for carotid artery stenosis isn't helpful and shouldn't be done.  For those of you considering such an examination as a gift for a loved one, why not choose a golf outing instead?

Other topics this week include infusion pumps for hard to control diabetes in the Lancet, medications for neuropathy in JAMA, and varenicline and a nicotine patch for smoking cessation in JAMA.  Until next week, y'all live well.

 

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imagesCAJIMJS6Most adults will have at least one episode of noteworthy back pain in their lifetime, with many experiencing persistent and often disabling symptoms. In fact, back issues are one major reason people miss work and/or seek medical attention.  Enter then the medicalization of this condition, with a fast forward to injections into the space around affected nerves emerging from the spine, so-called 'epidural' injections, to treat pain.  On PodMed this week Rick and I offer kudos to the authors of this study published in NEJM, assessing whether this strategy is actually of any benefit in alleviating pain.  While for those unfortunate folks who got a dose of fungus along with their injection for back pain this study comes too late, we hope it will turn the tide of epidural injections commonly being employed for this purpose.

Investigators randomized 400 people with lumbar spinal stenosis, or narrowing of the canal through which the spinal cord and nerves must pass down the back, and who also had moderate to severe leg pain because of the condition, to one of two treatments: epidural injections of steroid medication plus a local anesthetic called lidocaine, or simply lidocaine alone. Subjects could receive either one or two injections and were subsequently evaluated six weeks after their first (and perhaps only) injection. Both a disability and a pain scale questionnaire were utilized as the primary outcome measures.

People who received the steroid medication, ostensibly to reduce inflammation in the nerve root and the putative cause of the pain, did no better at the six week assessment than those who received the local anesthetic alone.  Wow!  As background it's worth noting that injections for spinal stenosis have increased by about 300% in Medicare and Veteran's Administration populations over the last two decades, with a concomitant increase in costs. So a huge amount of resources have been devoted to the employment of this technique and this study at least suggests we've been wasting our money.

To be fair it must be admitted that there are several causes of back pain other than lumbar spinal stenosis, and these may be amenable to this strategy.  These authors note that about a quarter of all epidural injections for back pain in the Medicare population and 75% of those in the VA population are due to this condition.  Clearly then the technique cannot be soundly panned until additional studies are carried out but Rick and I both feel it should be considered much more judiciously. As we have advocated in the past, the tincture of time is well worth attempting, and in the case of low back pain, so is weight loss and exercise, perhaps taught with a physical therapist's help.

Other topics this week include an assessment of how often physicians talk about sunscreen with their patients in JAMA Dermatology, bone marrow transplantation for sickle cell disease in JAMA, and celiac disease and a genetic assessment in NEJM.  Until next week, y'all live well.

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451096797Anyone out there remember the TV show 'The Bionic Man'? The central premise involves a guy who is severely injured and subsequently largely rebuilt using bionic parts.  What exactly is bionic?  Wikipedia defines the term this way: Bionics (also known as bionical creativity engineering) is the application of biological methods and systems found in nature to the study and design of engineering systems and modern technology.  Rick and I discuss a bionic pancreas on PodMed this week, based on a study presented at the American Diabetes Association meeting and published in NEJM. This study's senior author is a biomedical engineer who designed an artificial pancreas to resemble a human one, using both insulin and glucagon, the two hormones primarily responsible for regulating blood sugar, to manage same.  The early results look promising indeed, if not quite yet ready for prime time (pun intended).

The paper reports the results of two five-day trials, one in adults and one in adolescents, with type 1 diabetes, who were fitted with a bionic pancreas that automatically monitored blood glucose and utilized either insulin or glucagon to achieve a desirable level with an iPhone app interface.  Previous work by the same group established that in an inpatient setting, the device was capable of managing blood glucose effectively for 48 hours.

So what about the outpatient setting, where variability in all sorts of parameters that directly and indirectly affect blood glucose are operational? Assessing the device in this setting was the intention of the current study. All subjects had previous experience with insulin pumps and glucose monitoring. The adults were resident in a hotel geographically close to the hospital, and their activities were limited to an area within three square miles of the hospital for the duration of the study.  They were also accompanied by a staff member. During the study period they could eat whatever they liked, exercise at will, and were allowed to consume 3 alcoholic drinks per day for men and 2 for women.  The adolescents were resident in a camp for people with diabetes.  For the duration of the study they ate the same meals and participated in the same activities as other campers.  Both groups had abundant data collected on blood glucose, episodes of hypoglycemia and other adverse events, and they all acted as their own controls with a five-day usual care period during which all parameters were recorded as well.

Here's what they found: the bionic pancreas was able to decrease the number of episodes of hypoglycemia in the adult population but not in the adolescents.  The authors speculate this may be due to prompt intervention in the camp setting to avoid such an outcome. Both groups saw a lower mean blood glucose level with use of the bionic pancreas compared to usual care. There were a few issues with the iPhone interface but these spontaneously resolved and infusions resumed as appropriate. The authors caution that the device may overestimate blood glucose if acetaminophen is used, and that currently available glucagon must be reconstituted daily, but Rick and I agree that this is a great proof of concept study that clearly should be ramped up. And it's cool!

Other studies this week include thrombolysis for pulmonary embolism in JAMA, exercise for depression in JAMA Internal Medicine, and mammography outcomes in the BMJ.  Until next week, y'all live well.

 

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479517651Parkinson's disease (PD), a consequence of death of neurons in the brain area known as the substantia nigra, is the second most common neurodegenerative disease in the world, after Alzheimer's disease. This movement disorder affects about 7 million people worldwide and 1 million in the US alone currently, with more to come as many more of us age into our 80s and older since PD occurs more often as people age.  Now for the good news:  in what's known as a 'pragmatic' trial undertaken in the UK and reported in the Lancet, as Rick and I discuss on PodMed this week, an old drug known as L-DOPA or levodopa seems the best choice for most when it comes to initial medical management.

Pragmatic trials attempt to assess interventions as they are implemented in the real world rather than the rarified air of a clinical trial. In this case 1620 people newly diagnosed with PD were randomly assigned to either levodopa, another type of drug known as a dopamine agonist, or yet another class called monoamine oxidase type B inhibitors.  Each of these three types of drugs works by a different mechanism in an attempt to overcome loss of the neurotransmitter called dopamine, normally produced by the neurons that die. People entering the trial were diagnosed by movement disorder experts, were either untreated previously or treated for less than six months with levodopa.  Both subjects and clinicians were aware of which drug was selected.

Data from 7 years of follow-up is presented in this study.  One outcome measure was the mobility subscale of a questionnaire known as the PDQ-39. This self-report data is sensitive to items regarded as important to people with PD but that may not be represented on clinical rating scales. Quality-adjusted life-years were determined along with a host of other outcomes such as  changes in the mini-mental state examination, hospitalizations, and mortality. The study determined that for those assigned to the levodopa arm, small but persistent benefits in mobility scores by self-report were seen.  Moreover, with regard to compliance, "179 (28%) of 632 patients allocated dopamine agonists and 104 (23%) of 460 patients allocated MAOBI discontinued allocated treatment because of side-effects compared with 11 (2%) of 528 patients allocated levodopa (p<0·0001)."  As Rick and I opine in the podcast, this may be regarded as good news since levodopa is off-patent, we have an abundant track record regarding its use, and more sensitive titration of the drug clinically may preclude some of the side effects or at least delay them.

The authors have done a cost analysis that is forthcoming, but predict that the economic analysis will also favor use of L-DOPA.  Since we have so many people who will undoubtedly develop PD in the near term, this is of public health benefit as well.  Finally, Rick and I do mention other strategies such as electrode implantation as promising, but agree that for now, knowing which medication is likely to be most beneficial is very helpful for all concerned.

Other topics this week include two studies from NEJM on managing another common condition, obstructive sleep apnea.  We also look at statins and physical activity in older men in JAMA Internal Medicine, and what happens when insulin is added to metformin for the management of type 2 diabetes in JAMA.  Until next week, y'all live well.

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154216694How many children are maltreated, with 'maltreatment' including neglect, sexual, physical or emotional abuse, each year in the United States?  While it's a safe bet no one really knows the absolute number, a very sobering study Rick and I discuss on PodMed this week and published in JAMA Pediatrics attempts to estimate that number, with disconcerting results.  And by the way, almost everyone agrees said results are almost surely an underestimate.  Okay, what about the study?

Researchers crunched data from the National Child Abuse and Neglect Data System (NCANDS) Child File, which included reports on 5 689 900 children filed between 2004 and 2011 of maltreatment confirmed by Child Protective Services. The main outcome measures of the analysis include the cumulative prevalence of confirmed child maltreatment by race/ethnicity, sex, and year.

Here are the numbers, directly from the manuscript: "At 2011 rates, 12.5% (95% CI, 12.5%-12.6%) of US children will experience a confirmed case of maltreatment by 18 years of age. Girls have a higher cumulative prevalence (13.0% [95% CI, 12.9%-13.0%]) than boys (12.0% [12.0%-12.1%]). Black (20.9% [95% CI, 20.8%-21.1%]), Native American (14.5% [14.2%-14.9%]), and Hispanic (13.0% [12.9%-13.1%]) children have higher prevalences than white (10.7% [10.6%-10.8%]) or Asian/Pacific Islander (3.8% [3.7%-3.8%]) children. The risk for maltreatment is highest in the first few years of life; 2.1% (95% CI, 2.1%-2.1%) of children have confirmed maltreatment by 1 year of age, and 5.8% (5.8%-5.9%), by 5 years of age. Estimates from 2011 were consistent with those from 2004 through 2010."

Yikes!  I am especially taken aback by the fact that most maltreatment occurs while children are very young, and often preverbal. Rick and I both agree that the onus is on healthcare providers, who may be some of the few people who will interact with children at this point in their lives, to be on hyperalert to signs of maltreatment. Rick also points out, as do the authors of the study, that child maltreatment really is a health issue: those who have been maltreated as children are at greater risk for obesity, HIV infection, and mortality than those who have not been maltreated.  They're more likely to engage in criminal behavior, experience mental health problems, and are 5 times as likely to attempt suicide as their non-maltreated counterparts. Indeed, the authors provide the estimate that the cost to society of child maltreatment exceeds or equals that of stroke and type 2 diabetes!

Clearly, these rates of child maltreatment are intolerable.  As the authors state, "these data highlight that the burden of confirmed maltreatment is far greater than suggested by single-year national estimates of confirmed child maltreatment and that the risk for maltreatment is particularly high for black children (between 1 in 4 and 1 in 5, my addition)." This study provides us with greater awareness of the problem, now policies and practices must be developed and implemented to address what is obviously a public health issue.

Other topics this week include the utility of colorectal cancer screening in previously unscreened elderly in Annals of Internal Medicine, and two from the BMJ: early stroke thrombolysis benefit, and the statin/diabetes relationship.  Until next week, y'all live well.

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180957061Direct to consumer advertising on the part of pharmaceutical companies has gotten a lot of negative press, and with good reason, several studies have supported. That's because such advertising frequently stimulates people to demand specific medications from their healthcare providers, who often simply write the prescription rather than engage in a prolonged discussion about why or why not it is appropriate.  Now such advertising on the part of cancer treatment centers may also take it on the chin, with a study Rick and I discuss on PodMed this week in Annals of Internal Medicine.  The study examines the content of such advertising and we hope will at least bring awareness to the fore.

Researchers examined cancer center advertising content in the top 44 US television networks and 269 consumer magazines in 2012. During that time there were 409 unique clinical advertisements placed by 102 cancer centers. It's also worth noting that in 2012 more than 1500 cancer programs were accredited by the American College of Surgeons, and this number remains on a strong upward trajectory, along with a predicted increased in the number of cancer cases as the population ages; a 45% increase in cancer incidence is expected by 2030! Okay, so what about the ads?

The majority of both television and print advertisements featured treatments (88%), and were emotional in content (85%). Emotional appeals included evoking hope for survival in 61%, positioning cancer treatment as a fight or battle in 41%, and inducing fear in 30%. About half of the ads featured patient testimonials, usually focused on survival.

In contrast, only about 18% of the ads featured cancer screening, risks of therapy 2%, costs of therapy in 5%, and insurance matters 0%.  Disclaimers about outcomes were seen in only 15% of advertisements, and never described the results a typical patient might expect.  Hmmm.  If the rationale for placing ads includes a desire to provide potential patients with treatment options, this look at advertising practice seems a bit skewed at best.

So, should we either abolish or regulate more closely direct-to-consumer advertising?  Recognizing that the public has a vested interest in an answer to that question, an editorialist in the same issue of Annals reveals data from a survey asking the question of whether medical advertising directly to consumers should be modified or abolished, and the majority of respondents answered no. In point of fact only a small percentage were in favor of any regulation at all.  What then?  Rick and I agree that a more even-handed approach would be welcome, with perhaps development and advertisement of an objective, independent database comparing prices, services, and outcomes regionally and nationally among cancer centers.  Perhaps such a strategy, if utilized by consumers, would help level the playing field with regard to informing consumer choice.

Other topics this week include the possible utility of venlafaxine for hot flashes in menopause in JAMA Internal Medicine, several studies on treatments for pulmonary fibrosis in NEJM, and a new antibody for asthma treatment in the same issue.  Until next week, y'all live well.

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467090685Electronic cigarettes or e-cigarettes appeared to get some great press this week with the release of a study published in the journal Addiction, and one of the line-up Rick and I discuss on PodMed . The study's superficial conclusion is that folks who were attempting to quit smoking and who used e-cigarettes to support their efforts were more successful than either those who used other forms of nicotine replacement or those who tried to go cold turkey.  But hold up, everyone, turns out that a closer look at the methodology of the study as well as the interpretation of the data reveals a lot of holes, and doesn't really answer the question the study purports to ask: do e-cigarettes help people who'd like to stop smoking do so?  Let's see what they did.

Researchers in the UK enrolled almost 6000 adults who had smoked within the previous 12 months and made at least one attempt to cease smoking during that time. Of that number, the majority elected to make the attempt without use of nicotine replacement therapy bought over-the-counter (NRT), where the majority of nicotine replacement products in the UK can be found, while 1922 did utilize OTC NRT, and 464 used e-cigarettes. Surveys were administered to the subjects as part of the ongoing UK Smoking Toolkit Study, which is attempting to gather information about smoking behaviors in England. For this study data from July 2009 through February 2014 was aggregated with the following exclusions: folks who combined methods such as e-cigarettes and NRT, prescription NRT use, or behavioral therapy. The primary outcome measure was self-reported smoking cessation.

Briefly, the study finds "the adjusted odds of non-smoking in users of e-cigarettes were 1.58 (95%CI 1.13 to 2.21) times higher compared with users of NRT bought over-the-counter and 1.55 (95%CI 1.14 to 2.11) times higher compared with those using no aid. In another model that included another measure of dependence (HSI; missing data 3%, n=172), the adjusted odds of non-smoking in users of e-cigarettes were 1.63 (95%CI 1.15 to 2.32) times higher compared with users of NRT bought over-the-counter and 1.43 (95%CI 1.03 to 1.98) times higher compared with those using no aid."  Simply put, those who used e-cigarettes were 1.5 times more likely to quit successfully compared to those using other methods.  Now, what about the holes?

Importantly, Rick points out, there was no assessment of durability of self-reported quitting. In contrast to almost all of the available evidence, this study pans NRT, at least as obtained over-the-counter.  And clearly, we wouldn't be true to our biases if we didn't state that the best and most convincing evidence remains to be gathered: a prospective, blinded, randomized trial of a large number of matched smokers comparing the methods of achieving smoking cessation over a prolonged period of time.  Wonder if e-cigarette manufacturers, so reluctant to have their products regulated as smoking cessation aids, would step up to such a funding opportunity?

Other topics this week include two from JAMA: genetic analysis and lung cancer treatment, and bronchitis and antibiotic treatment, and one from Diabetologia on the risk of cardiovascular disease in women with diabetes.  Until next week, y'all live well.

 

 

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178362592Should you quaff red wine and consume other sources of resveratrol, one of the compounds that's purported to impart health benefits found in this beverage as well as chocolate, berries, grapes and some roots?  Not according to a study Rick and I discuss on PodMed this week, and as reported in JAMA Internal Medicine by our colleague Richard Semba.  Here's what they did: almost 800 residents of the Chianti region of Italy 65 years and older were enrolled in this study, called Invecchiare in Chianti (InCHIANTI) Study (“Aging in the Chianti Region”).  Got to love the Italian! Roughly equal numbers of men and women were enrolled.

Study participants were followed for 9 years, during which time just over 34% of them died. Urinary metabolites of resveratrol were measured at baseline from 24 hour urine samples. Blood tests for inflammatory markers, glucose, and cholesterol and triglycerides were performed. Data on alcohol consumption, smoking status, and physical activity were also collected by self-report. Nutritional supplements were used by less than 1% of the study population.

The dataset was divided into quartiles based on resveratrol metabolites.  Interestingly, the highest quartile also had the greatest number of men, current smokers, and those who both consumed more alcohol and exercised more, and had the least degree of cognitive impairment as assessed with the Mini-Mental State Examination (MMSE).  Those in the lowest quartile experienced more diabetes and coronary artery disease.

Based on the previous findings, it might seem predictable that other factors would also vary according, but as is stated in the study, "There were no significant differences across the quartiles of total urinary resveratrol metabolite concentrations by age, education, BMI, CRP, IL-6, IL-1β, TNF, mean arterial blood pressure, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, or by prevalence of hypertension, heart failure, peripheral artery disease, stroke, cancer, and chronic kidney disease."  Finally, regarding the hard endpoint of death: "Total urinary resveratrol metabolites concentration was not significantly associated with mortality in models adjusting for age, sex, BMI, serum levels of lipids, chronic diseases, and other variables."  Additional analyses and adjustments were made and the lack of any positive association with a reduced death risk persisted.

This certainly is disappointing for those of us who've bolstered our consumption of red wine with the comforting supposition that it's good for us! Yet as both the author of the study and Rick intone, we should simply drink good wine, and not worry about whether it will prolong life since it clearly helps in enjoying life more.  Additionally, we do know that modest alcohol consumption, a glass for women and a couple of glasses for men each day, does reduce cardiovascular events.  What about supplementation with higher doses of resveratrol?  This study can provide no data on that practice since these were dietary levels presumably achieved with wine consumption, but based on the lack of any hint of a benefit in this study, sure seems like this is one more supplement for the slag heap.

Other topics this week include complications of male circumcision with age in JAMA Pediatrics, football, concussion and change in the volume of the hippocampus in JAMA, and a novel treatment for metastatic cancer in Science.  Until next week, y'all live well.

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