056002536-close-person-practicing-cpr-chHave you ever witnessed someone having an apparent heart attack when you've been out and about? I did once, while riding my bike on a local trail, and fortunately, my cycling partner, a dentist, thought to look in the man's mouth while CPR was being performed and thus removed his dentures, which had fallen down and were blocking his airway. The man survived to be transported to the hospital. On PodMed this week, Rick and I discuss a study published in JAMA Cardiology demonstrating the benefits of bystander-initiated CPR in just such circumstances, which has resulted in many more survivors among those who have an out-of-hospital cardiac arrest (OHCA).

The study looked at the impact of public health initiatives undertaken in North Carolina to improve resuscitation attempts for those who experienced an OHCA from 2010 through 2014. Almost 8300 persons had an OHCA, either publicly or at home, where CPR was initiated. The percentage of CPR initiation increased from about 28% to 41% for at home events, and from about 61% to just over 70% for those OHCAs taking place in public. Survival to discharge also improved among both groups, from 5.7% to 8.1% for at home events, and from 10.8% to 16.2% for public events. Use of automatic external defibrillators did not change for the public setting but did in at home arrests. Clearly abundant evidence for the benefit of public awareness campaigns, leading Rick and me to advocate that everyone should know CPR.

Other topics this week include Long-Acting β-Agonists (LABA) Combined With Long-Acting Muscarinic Antagonists or LABA Combined With Inhaled Corticosteroids for Patients With Stable COPD and Association Between Use of Non–Vitamin K Oral Anticoagulants With and Without Concurrent Medications and Risk of Major Bleeding in Nonvalvular Atrial Fibrillation in JAMA, and Predicting 30-Day Mortality for Patients With Acute Heart Failure in the Emergency Department: A Cohort Study, in Annals of Internal Medicine. Until next week, y'all live well.

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042105054-cigarettes-tied-rope-and-wickShould we ban combustible cigarettes for e-cigarettes? Such an action would result in considerable healthcare cost savings and substantially reduce deaths relative to smoking, the authors of a paper in Tobacco Control, a BMJ publication, argue this week, while Rick and I debate what we actually know about the long term effects of e-cigarettes on PodMed even as we applaud the prospect of the elimination of combustible cigarettes. Here's what the researchers did:

The authors created two models for predicting the impact of outlawing combustible cigarettes and replacing them with e-cigarettes in the United States, one called an Optimistic Scenario and the other a Pessimistic Scenario. Each calculated deaths averted and healthcare costs avoided if such a change took place over a ten year period. These were compared with a Status Quo model where no changes were implemented, and all models considered the time period from 2016 to 2100 per age and sex, and projected mortality. By their calculations the Optimistic Scenario "yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost" while with the Pessimistic Scenario "1.6 million premature deaths are averted with 20.8 million fewer life years lost." That's a lot of death and life lost, let alone healthcare costs for lung cancer and COPD. Predictably, Rick and I vote yes!

Other topics this week include Tattoo Pigment–Induced Granulomatous Lymphadenopathy Mimicking Lymphoma in Annals of Internal Medicine, A single mutation in the prM protein of Zika virus contributes to fetal microcephaly in Science, and Association of Health Literacy With Outcomes in Patients Undergoing Abdominal Surgery in JAMA Surgery. Until next week, y'all live well.

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iStock_000068724623_MediumIf you're over the age of fifty you may think you're at low risk to become infected with HIV, but new data published in the Lancet this week that Rick and I discuss on PodMed may cause you to rethink that notion. This huge dataset looks at new cases of HIV infection in adults aged fifty or older from 31 European countries, between 2004 and 2015. The study found that one in six new cases of HIV infection over this time period occurred in those over the age of 50, and that such new cases were more likely to be advanced at the time of diagnosis, as evidenced by a low CD4 count, and that the most common means of transmission was heterosexual sex.

Well. As we discuss in the podcast, most older people think they're not at risk to acquire HIV, and the authors note that services directed toward testing and HIV-related care are skewed toward younger people. Even clinicians, or especially clinicians, don't think about the fifty+ crowd when considering the infection. This in spite of the WHO and the CDC advocating for universal testing for HIV status. That's everyone, folks.

Other topics this week include Low-Dose Aspirin Discontinuation and Risk of Cardiovascular Events in Circulation, and two from JAMA: Effect of Genotype-Guided Warfarin Dosing on Events and Anticoagulation Control and Trends and Patterns of Differences in Chronic Respiratory Disease Mortality Among US Counties, 1980-2014. Until next week, y'all live well.

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iStock_000056500374_MediumShould physicians assist people who wish to die to do so? That roiling debate continues, but several states have moved forward with laws that delineate and enable the process, among them Oregon. A study of Oregon's experience with the Death With Dignity Act over the last twenty years along with the American College of Physician's position paper and two great editorials on physician assisted suicide are published in Annals of Internal Medicine this week and comprise fodder for spirited debate for Rick and me on PodMed. Wow, that's a sentence.  Here goes:

First of all, Oregon stipulates their language as death with dignity rather than physician-assisted suicide, which can be considered an important distinction. Since passage of the act 1857 residents of Oregon have received prescription medicines to achieve their own death. Of this number 64% chose to utilize the medicines. Overall the rate of death with dignity deaths is 54.6 per 10,000 deaths, so relatively few choose to exercise this right. Following passage of the act the rate at which people exercised their right increased over several years but now seems to be stable. One ongoing concern relative to this practice is that people who are uneducated or otherwise vulnerable would be disproportionately channeled into making this decision. Oregon's experience seems to show that on the contrary, those who choose to end their own lives are on the higher end of the education spectrum and seem fully able to appreciate their choice.

Also in this issue of Annals is the aforementioned position paper, coming out against physician participation in assisted suicide, and advocating instead for palliative care physicians to step into the place of assuring that all measures for comfort and relief of symptoms are employed. Is this adequate? According to the issues people in Oregon have identified regarding their desire to be able to choose their own time of death, no. Intractable pain is not primary, but rather loss of autonomy figures large, and a palliative care consult is unlikely to resolve that. My own view, informed by exposures in the role of chaplain, is that people who are carefully screened and assessed should be given a choice, and physicians are the gatekeepers of that. Rick disagrees, and we both are thankful for the thoughtful and respectful debate of many on either side of the issue.

Other topics this week include Death and Cardiac Arrest in U.S. Triathlon Participants, 1985 to 2016: A Case Series, also in Annals, Weight and Other Outcomes 12 Years after Gastric Bypass in NEJM, and in JAMA Effect of Post–Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese WomenA Randomized Clinical Trial. Until next week, y'all live well.

 

 

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021927502-medicine-pillsWhy are prescription drugs so expensive? One answer to that question is unquestionably greed, as evidenced in a study in JAMA Internal Medicine Rick and I discuss on PodMed this week. And while that conclusion is completely expected, some of the details and the extent to which pharmaceutical companies are manipulating data and information are noteworthy, and worth protesting.

This study took a look at 10 new cancer drugs from 10 companies, using data provided to the US Securities and Exchange Commission to pinpoint research and development (R&D) costs by the pharmaceutical companies.  The authors found that the median time to develop a new drug was 7.3 years at a cost of $648 million. Here's what the drug makers earned:"The revenue since approval is substantial (median, $1658.4 million; range, $204.1 million to $22 275.0 million). Taken in aggregate, profits in about 4 years post approval were about 9 times the costs of bringing the drug to market. One element included in the data pharma provides to the SEC is that research undertaken with public dollars in research grants to universities, a cost that should clearly be removed. And finally, these numbers are very different from those provided by pharma to justify huge price tags on new drugs relative to R&D.  As Rick and I agree, profit is fine, gouging is not. In view of the fact that most people with cancer cite financial concerns as a major source of worry, some scrutiny and modification of this practice seems indicated. It's also worth noting that such price gouging is not limited to cancer drugs, and is something that cries out for redress.

Other topics this week include two from JAMA:Effect of Sentinel Lymph Node vs Full Axillary Dissection on Overall Breast Cancer Survival and Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality, and in NEJM: Hospital-Readmission Risk — Isolating Hospital Effects from Patient Effects. Until next week, y'all live well.

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036507010-vaccineResponsible parents everywhere seek to protect their children, and for some, that means avoiding routine immunizations for a host of unsubstantiated reasons. Now a research letter Rick and I discuss on PodMed this week as published in JAMA details a trend that's rather disturbing, where parents in California are seeming to seek medical exemptions for their children since the personal belief loophole regarding avoiding vaccination has been closed. Here's the story:

Prior to the 2016-17 school year, California bill (SB)277 eliminated the personal belief exemption from school vaccine mandates, which had allowed parents to cite religious or philosophical objections to required vaccines but enroll their children in school. The exemption for medical reasons remains, and was in fact expanded somewhat under the bill. The authors examined data from 1996 to 2016 from incoming kindergartners and tallied statewide medical and personal belief exemptions over the time period. In the first year under the new law, medical exemptions increased from 0.17% to 0.51%, while exemptions for personal beliefs dropped from 2.37% to 0.56%. Clearly, while there was an overall decrease in exemptions it appears that some have shifted to a medical exemption. And as Rick opines, that's gaming the system, with physician collusion. It's well known that herd immunity depends upon a large number of us being immunized, so choosing not to do so has potentially deleterious or even deadly consequences for others. We both agree that exemptions need to be closely scrutinized for the good of all.

Other topics this week are all from NEJM: Third Dose of MMR VaccineTiotropium in Early-Stage COPD, and Tezepelumab in Adults with Uncontrolled Asthma. Until next week, y'all live well.

 

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iStock-157614058Fat has been excoriated in the diet world for decades, but now a study known by the acronym PURE has challenged conventional wisdom, Rick and I discuss on PodMed this week. The study was published in the Lancet and presented at the European Society of Cardiology meeting, and caused me to ask "should you live PURE?" Here's what you need to know to answer that question:

The acronym PURE stands for Prospective Urban Rural Epidemiology study, and it was conducted in over 130,000 low and middle income participants in 18 countries between 2003 and 2013, with a median follow up of 7.4 years. Using that favorite tool, the validated food frequency questionnaire, researchers carefully assessed specific nutrient intake and correlated that with total mortality and major cardiovascular events. Correlations were calculated based on carbohydrate, total fat, saturated fat, polyunsaturated fat and monounsaturated fat. In short, the study found that high carbohydrate intake was associated with greater risk of mortality, while fat of any type was associated with a lower risk. Neither total fat nor types of fat were associated with cardiovascular disease, heart attacks or death from heart disease, and most interestingly, there was an inverse relationship of fat consumption and stroke. Well.  Flies in the face of years of previous research, no? As Rick and I discuss in the podcast, there is no assessment of exercise or daily activity, often higher in those of low and middle income, nor is there data on BMI. One question that arises is is higher fat consumption in those of lower BMI and higher daily activity advantageous?

Other studies this all-heart week include two from NEJM:Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease and Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation, and in Annals of Internal Medicine: Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Status. Until next week, y'all live well.

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047081331-cannabis-leafAnecdotal reports abound about the ability of cannabis or marijuana to relieve chronic pain and the anxiety associated with post traumatic stress disorder, or PTSD, but do these claims have any basis in fact? On PodMed this week, Rick and I examine two studies in Annals of Internal Medicine, and agree with the authors that the evidence is lackluster at best. What did they do?

Both studies are meta-analyses, so admittedly hypothesis generating rather than conclusive.  With regard to chronic pain, the study notes the fact that 28 states and DC have legalized marijuana for medical purposes. Some of those same places have also done so for recreational purposes as well, yet the strength of the evidence that cannabis provides effective pain relief from 27 pain trials cited is of low quality. The harm side of cannabis use appears to be robust: 11 reviews and 32 primary studies indicate increased motor vehicle accidents, cognitive impairment and psychotic symptoms.

What of PTSD? This review states that more than one-third of those seeking cannabis in states where it is legal list this condition as their reason for doing so. With regard to evidence for its use, only two reviews and three observational studies were found, with no randomized trials. The authors conclude that our best hope is ongoing trials currently underway that are examining cannabis use in a more rigorous fashion.

Other topics this week include ABIM Maintenance of Certification: Randomized Trial of Open-Book Versus Closed-Book Examination, also from Annals, and two from NEJM:Five-Year Outcomes for
On-Pump vs. Off-Pump CABG
 and Cognitive Function in a Trial of Evolocumab. Until next week, y'all live well.

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sick-child-photo-020647220_iconm-120x86Sounded like a great idea at the time: a flu vaccine that could be given via nose droplets rather than an injection, especially for kids. Now, as Rick and I discuss on PodMed this week and published in the New England Journal of Medicine, turns out kids are the very persons for whom this vaccine is essentially ineffective.  Sorry parents, it's back to the tried but true along with the tears, at least for now. What happened?

Vaccines against influenza are routinely assessed for their ability to prevent the infection. The two types of vaccines, killed or inactivated, which is administered by injection, and live attenuated, given by the nasal droplet method, are most often used in adults and children, respectively. In the 2013-14 flu season it was detected that the live attenuated vaccine was essentially ineffective in the pediatric population. The vaccine was reformulated and used in the 2015-16 season, where once again, data from this analysis indicate it was ineffective in preventing flu in those who received it, only providing an effectiveness of about 15%. This lackluster performance has caused the powers that be, including the WHO and the CDC, to advise parents to go back to the injection for their children.  What's still not known is why this happened, as early use of the live attenuated vaccine did seem efficacious. Only more study will tell.

Other topics this week include Screening for Nasopharyngeal Carcinoma, also in NEJM, Expansion of Treatment for Hepatitis C Virus Infection by Task Shifting to Community-Based Nonspecialist Providers: A Nonrandomized Clinical Trial in Annals of Internal Medicine, and in JAMA: Cerebral Embolic Protection in Patients Undergoing Surgical Aortic Valve Replacement. Until next week, y'all live well.

 

 

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iStock_000014270773_MediumIf you need a kidney transplant you've got a bunch of things to think about, and it would be great to check worries about kidney rejection off the list.  That may be possible with a new method for depleting antibodies from the blood of the recipient Rick and I talk about on PodMed this week, as published in the New England Journal of Medicine. The study uses an enzyme made by the bacterium Streptococcus pyogenes abbreviated IdeS to deplete the class of antibodies known as IgG.

Twenty-five people who required kidney transplantation were enrolled in this trial, 11 patients in Sweden and 14 in the US. All of them were highly sensitized, meaning they had high levels of antibodies that couldn't be depleted by other means. IdeS was able to eliminate IgG and another type of antibody entirely at the time of transplantation. Of the 25 kidneys transplanted, 24 functioned in the recipient. One transplanted kidney ultimately failed after antibodies other than the type depleted by the enzyme developed.

This study is good news for the many, many people who are waiting for kidneys on transplant lists as it allows kidneys that are not ideal from a matching standpoint to be received by folks with a bunch of antibodies on board. It may also prove useful for those who require two or more kidney transplants in their lifetime as they definitely become sensitized.

Other topics this week include Fees for Certification and Finances of Medical Specialty Boards in JAMA, Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health in Annals of Internal Medicine, and back to NEJM for Idarucizumab for Dabigatran Reversal. Until next week, y'all live well.

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