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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Screen Shot 2015-06-12 at 10 24 12 AM (2)It's a good bet no one really wants to have a prosthetic leg, but if you need one, the latest iteration as described in JAMA this week and Rick and I discuss on PodMed may be the ticket.  This study had this laudable objective: " To determine the effect of including electromyographic (EMG) data and historical information from prior gait strides in a real-time control system for a powered prosthetic leg capable of level-ground walking, stair ascent and descent, ramp ascent and descent, and natural transitions between these ambulation modes."  Wow. In real time it means that the prosthetic leg used in these 7 patients, all of whom had above-knee amputations but previous use of a prosthesis, both historic and real-time data was gathered and integrated into control of the leg and number of missteps calculated.  In short, the prosthesis was able to reduce the number of missteps, and presumably the likelihood of a fall, and performed well over terrains including stairs and ramps as well as in transitions between them.

One concern I raise to Rick is cost, and that's not addressed here, nor is reliability of this complex prosthesis, but it sounds like an advancement for many.  Other topics this week include surgical mishaps in JAMA Surgery, early CPR and mobile activation in NEJM, and the relationship between obesity and breast cancer, in JAMA Oncology.  Until next week, y'all live well.

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iStock_000020076031_MediumWhen a tumor is removed from the breast, can an approach where the surgeon removes just a bit more tissue surrounding the tumor itself result in fewer reoperations and a lower risk of recurrence, so-called 'cavity shaving'?  A study Rick and I discuss on PodMed this week, and published in the New England Journal of Medicine concludes the answer is yes, with the need for reoperation and risk for recurrence in early stage breast cancer reduced by about 50%.  That's impressive, and well worth considering when a woman has to undergo surgery to remove a breast tumor.

For whom is such an approach warranted?  Women with early stage, smaller tumors, generally speaking. David Euhus, head of breast surgery at Johns Hopkins and author of an earlier study looking at the same issue, says considerations like contour of the breast and symmetry between them also enter the picture, but even so, he advocates for breast sparing surgery for most women and lauds this study.  Other topics this week include breast cancer screening recommendations, long term follow-up in those under treatment for type 2 diabetes, and the addition of another agent to statins to reduce LDL cholesterol and outcomes, all in NEJM.  Until next week, y'all live well.

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iStock_000002874391_MediumNewer oral contraceptives, heralded as providing effective birth control at lower doses and often used to stabilize both menstrual cycles and mood in some women, have been shown to be associated with about twice the risk of developing blood clots, known in the parlance as venous thromboembolism or VTE, when compared with older formulations, a study Rick and I discuss on PodMed this week and published in the British Medical Journal concludes.  As compared with women who have no exposure to oral contraceptives at all the risk is about 4 times higher for VTE, which can be fatal.  Rick points out that while the relative risks are certainly alarming, the absolute risk of blood clot formation is still quite low, about 14-17 excess cases of VTE per 10,000 women treated per year.  Rick offers the opinion that based on this data, which is from a large number of women treated over a lengthy period, if women are going to use oral contraceptives perhaps they should choose the older formulations, but he also advocates for a discussion with a care provider to weigh the relative risks and benefits.

Other topics this week include aflatoxin and gallbladder cancer, and an association between elevated thyroid hormone levels and fracture risk, both in JAMA, as well as efflux of high density lipoprotein and heart disease in the Lancet Diabetes and Endocrinology.  Until next week, y'all live well.

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iStock_000016798528_MediumWhen someone comes to the emergency department complaining of chest pain, a heart attack or other heart issue comes immediately to mind and a host of assessments ensue, often resulting in admission to the hospital.  Is that really necessary after negative findings in the ED?  That's one study Rick and I discuss on PodMed this week, as published in JAMA Internal Medicine.  The authors took a look at over 45,000 enrollees in a database collecting information from adult patients complaining of chest pain and with negative biomarkers for heart problems.  When these patients were admitted to the hospital, how often did heart attack, arrhythmia, cardiac or respiratory arrest or death occur?  An astonishingly low 0.06% of the time, or 4 out of 7266 patients, with 2 of those events a consequence of hospitalization.  Sure seems like not admitting these folks to the hospital is a reasonable strategy, but Rick and I agree that because of physician attitudes may take quite some time to penetrate clinical practice.

Other topics this week include a new treatment for asthma in NEJM, sciatica and steroids in JAMA, and in the Lancet, consequences of treatment with lithium.  Until next week, y'all live well.

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iStock_000056753446_MediumKudos to creative scientists this week on PodMed, as Rick and I highlight a study in Science taking a look at the benefits of measles vaccination in preventing other infections and deaths!  In a complex paper working with the knowledge that folks who've had measles infection experience a period of immunosupression, rendering them susceptible to a host of other infectious diseases, these investigators decided to examine death data for children aged 1 to 9 in Europe and 1 to 14 in the United States before and after mass measles vaccination campaigns were undertaken.  Lo and behold, preventing the immunosuppression relative to measles infection did decrease deaths due to other infectious disease.  The authors propose that the well-known fact that measles vaccination has reduced child mortality in resource-poor regions of the world by 30-50% can be explained by this mechanism.  Rick and I take the stance that this is yet one more reason for parents to take a look at the facts and make sure their children are vaccinated, both for their own benefit and for all of us.  We agree with the authors' sentiment that measles vaccination is one of the greatest public health triumphs ever undertaken.

Other topics this week include incentivizing smoking cessation in NEJM, and two from JAMA Internal Medicine: dangers of different forms of testosterone supplements, and sonography of the arm for blood clot detection.  Until next week, y'all live well.

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iStock_000021002106_FullClostridium difficile, or C. dif, as it is abbreviated in medical parlance, is well-known to healthcare providers, infecting many patients and killing some, especially older folks who are hospitalized or people who are immunocompromised.  How best to manage this mostly hospital-acquired or nosocomial infection has been a subject of active research for years, since antibiotic treatment isn't always successful and reinfection or recrudescence is common.  Enter now spore transplant, as Rick and I discuss on PodMed this week, and as described in a JAMA paper.  The strategy follows on the heels of fecal transplant, first attempted with fresh stool introduced through the rectum, then via swallowed capsules.  These researchers reasoned that introduction of a strain of Clostridium that doesn't produce toxins could result in colonization of the colon such that the toxigenic strain couldn't get a foothold.  Lo and behold, that's exactly what happened with oral administration of capsules containing spores of the non-toxin forming organism.  And as I opine in the podcast, there's also substantially less 'yuck factor' with this treatment.  Phase III, anyone?

Other topics this week include cardiovascular risk factors for adolescents in low and middle income countries, in the Lancet, a lariat device for atrial fibrillation in JAMA Internal Medicine, and digoxin and mortality in the European Heart Journal.  Until next week, y'all live well.

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iStock_000021763916_LargeInappropriate use of prescription opioid medications is permeating all segments of society, and now, sadly, is impacting newborns, as Rick and I discuss on PodMed this week.  'Neonatal abstinence syndrome,' where neonates may manifest a host of symptoms such as irritability, rigid muscles, instability in blood pressure, and even seizures, secondary to mom's opioid use, has increased markedly over the last 15 years, with this analysis of neonatal ICU admissions from 2004 to 2013 and published in the New England Journal of Medicine painting an even more dismal picture.

While previous reports had cited a three-fold increase in the incidence of neonatal abstinence syndrome from 2000 to 2009, this analysis finds an almost four-fold increase, with almost 20% of all NICU days nationally devoted to caring for these infants in 2013. Clearly, greater education of clinicians as well as pregnant women and those contemplating pregnancy is indicated, as well as research in how best to manage the condition, especially with regard to medications used in this population.

Other topics this week include a new vaccine for herpes zoster, also in NEJM, benefits of early and complete HPV vaccination in Pediatrics, and a lack of benefit seen with inferior vena cava filters in JAMA.  Until next week, y'all live well.

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iStock_000012940072_LargeType 1 diabetes is no fun for anyone, and it's especially problematic because it most often afflicts the young, who then must endure a lifetime of management strategies, all too often unsuccessful and increasingly onerous.  So if you're a parent of one child with type 1 diabetes, you'd unquestionably like to avoid the disease in subsequent children, known to be at risk.  Now, as Rick and I discuss on PodMed this week, that may be possible by actually using insulin as an immunogenic agent. That's as reported in JAMA.  Wow! we say.  What a novel and unique approach to the problem, for which we offer kudos.

Researchers identified 25 children who were at risk to develop type 1 diabetes based on family history and genotype, who were randomized to oral insulin of varying doses or not over a 3 to 18 month period.  Children were followed up to assess their immune response to insulin exposure with an eye toward inducing tolerance.  More profound T-cell responses were seen with the highest dose of insulin, and no hypoglycemia events occurred.  The investigators are moving forward into a phase 3 trial, so good news potentially for children at risk.

Other topics this week include another in JAMA, autism and vaccination (!).  One from NEJM- sequelae of Ebola virus infection, and in Neurology, guidelines on the management of first time seizure in adults.  Until next week, y'all live well.

 

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