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.

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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.

 

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iStock_21807349_MEDIUMIf you eat less, even if you're of normal weight, you'll live longer, many researchers conclude from studies on monkeys and other animals.  Now, as Rick and I discuss on PodMed this week, a study in JAMA Internal Medicine demonstrates that calorie restriction improves a number of other quality of life factors, and Rick reveals he's already adopted the behavior!  What gives?

This study, known by the acronym CALERIE 2, randomized 220 men and women with a normal BMI to 2 years of 25% calorie reduction or consumption per usual.  Outcome measures utilizing self-administered questionnaires included mood, depression, quality of life, perceived stress, sleep quality and sexual function. At the end of two years, compared with the consumption as usual group, the calorie restricted group reported better mood, reduced tension, improved general health, improved sex drive and relationship, and improved sleep! There was a positive correlation with greater weight loss. Well. Seems like even if you don't live longer you'll live better by voluntarily restricting your food intake, and as Rick quips in the podcast, so will your partner.  Or should I say pardner. And we also discuss previous research that demonstrates decreased inflammatory markers, so sounds like such a choice may be a win-win.

Other topics this week include obesity trends and USPSTF recommendations for syphilis screening in JAMA,  and a look at the Mediterranean diet, weight gain and fat distribution in the Lancet.  Until next week, y'all live well.

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iStock_000063632745_MediumSuicide rates are increasing nationally, and they're also increasing among soldiers in the US Army. Now a study in JAMA Psychiatry Rick and I discuss on PodMed this week attempts to take a look at the multitude of factors that surround a suicide attempt in an Army enlistee, clearly with an eye toward intervention at risky times.  What did they find?

Records of regular Army soldiers from 2004 to 2009 were examined, and 9650 suicide attempts were identified. Here's what investigators found: "risk estimates for sociodemographic and mental health predictors were highest among those never deployed, and currently and previously deployed soldiers had the highest risk of attempt by firearm. Risk was highest in the second month of service (never deployed), sixth month of deployment (currently deployed), and fifth month after return (previously deployed)." A few other findings worth noting: women were more likely to attempt suicide, as were those whose Army career spanned two years or less, and both depression and post traumatic stress disorder were risk factors.   Rick and I agree that figuring out who is at risk and conducting targeted screening among those who fit the profiles might help bring down the rising rate of suicide among those in the Army, which has exceeded that in the general population beginning in 2008. We hope that such studies might also inform effective screening strategies that might be employed among the civilian population as well.

Other topics this week include Zika and microcephaly modeling in NEJM, and in Annals of Internal Medicine, public reporting of mortality data and the impact of improving HIV control in South Africa.  Until next week, y'all live well.

 

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iStock_000065162681_MediumBariatric surgery, or obesity surgery, is now being recommended for many people with type 2 diabetes (T2D), and thus should undergo a name change: metabolic surgery, as Rick and I report on PodMed this week.  That's according to a rather large consensus of 48 professional organizations, including the American Diabetes Association, and published in Diabetes Care.

There are 11 studies published in this issue of the journal and reviewed in the development of the guidelines that address various aspects of metabolic surgery, including the several types of operations available, people in whom they are indicated, and the role of diet and exercise. The authors assert that they are not advocating that surgery should be a first step in managing diabetes, but rather that some procedure is indicated in those with a BMI greater than 40 or those with a BMI of 35 or more and whose diabetes isn't managed well with other methods.

Of note to Rick and me is the cost-effectiveness aspect of metabolic surgery in managing T2D and therefore avoiding many of the complications of the condition.  This is especially interesting given that such an expansion of metabolic surgery as proposed in these guidelines would present a huge up front cost to the health care system.

Other topics this week include two from JAMA: management of hypertension in the elderly and sodium in those with chronic kidney disease, and in the Journal of Clinical Oncology, a look at what people with advanced cancer hear from physicians about their condition. Until next week, y'all live well.

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iStock_000090618793_MediumIf you have knee osteoarthritis, management seems to come down to a couple of choices: live with it, try physical therapy or PT, or have a total knee replacement. Weight loss is also often helpful.  Now, as Rick and I discuss on PodMed this week, and as published in Annals of Internal Medicine, another option is available: Tai Chi.

Tai Chi, of course, has appeared any number of times in the medical literature lately, and has proven helpful in reducing falls in the elderly.  Now this study took just over 200 people with both symptomatic and radiographically confirmed knee osteoarthritis (OA) and randomized them to 12 weeks of Tai Chi twice per week or 6 weeks of PT twice per week followed by 6 weeks of home exercise. Follow-up continued at intervals to 52 weeks, at which time no significant difference was found between the PT and Tai Chi groups with regard to a composite score of knee function known as WOMAC.  There were differences, however, in both depression and the physical quality of life component, both of which were better with Tai Chi. Rick and I agree that this ancient art seems well worth trying especially as it also appears to have multiple health benefits.

Other topics this week include a surprising rate of 'silent' heart attack or myocardial infarction in Circulation, a survey of what physicians can talk about with regard to guns in the home, also in Annals of Internal Medicine, and in JAMA a new model for targeted, personalized lung cancer screening.  Until next week, y'all live well.

 

 

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iStock_000020932248_MediumHave you had a colonoscopy?  Jokes abound about this screening exam for colorectal cancer, but it's no joke that death rates from this form of cancer have declined quite a lot since such testing has become routine.  Then why not, as published in Annals of Internal Medicine this week, make the procedure more comfortable for patients by using carbon dioxide to inflate the colon rather than other gases? Rick and I agree on PodMed this week that this is one area where patients can, and likely should, advocate strongly for themselves.

The paper reviews the evidence that CO2 is easily administered, is much more readily absorbed from the gut and exhaled through the lungs rapidly after being used to inflate the colon, and adds less than $2.00 to the cost of the exam after purchase of needed equipment. CO2 overcomes the sometimes significant pain patients experience post-procedure when room air is used to expand their colon, as well as the occasional leakage of feces. It's rather daunting to read the authors' assertion that slow adoption of CO2 insufflation is due to a lack of importance assigned to improvement of patient experience.  So the word on the street if you're scheduled for a colonoscopy, ask about CO2.

Other topics this week include infant swaddling and SIDS in Pediatrics, and the impact of providing care to the chronically ill for caregivers and the significance of symptoms in smokers, both in NEJM.  Until next week, y'all live well.

 

 

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iStock_000068724623_MediumWhen it comes to the relationship between depression and dementia, a chicken or egg question seems to arise, Rick and I agree on PodMed this week. Who wouldn't be depressed at receiving a diagnosis of dementia?  And if one is depressed, it stands to reason that other cognitive processes might be affected.  So this study, published in the Lancet Psychiatry, followed over 3000 study participants since 1990 and took a look at the course of depression, not just a single snapshot, to try to discern the relationship. Investigators conclude that in folks with progressive and unremitting depression, there does seem to be a relationship with the development of dementia, while in those whose depression resolves or remains low such a relationship is not seen.

Admittedly, of the cohort of 3000+ people, all of whom were free of dementia at the outset, only 434 developed dementia, with the number whose depression was progressive much lower than that.  It would be compelling, of course, if the cohort had been 10 times that and the same conclusions found.  The authors speculate that depression that is unremitting and progressive may be a prodrome for dementia and if this is validated, may prove helpful in targeting people for testing potential interventions, and we agree.

Other topics this week include the most common emergency surgeries in JAMA Surgery, and management of insomnia as well as a look at long term complications of implanted defibrillators in Annals of Internal Medicine.  Until next week, y'all live well.

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iStock_000044075022_MediumPlacing a tablet with an allergen under someone's tongue to help ameliorate allergic responses has been around for a bit and is known as 'sublingual immunotherapy', but now, as Rick and I discuss on PodMed this week, the strategy was tried in people with moderate to severe asthma who were allergic to dust mites to try to reduce asthma attacks or exacerbations when corticosteroids were tapered.  Wow, that's a mouthful in describing the study population, but the upshot is it is desirable both to reduce corticosteroid use in these folks but also to avoid hospitalizations relative to asthma attacks. The study was published in JAMA, and the news is good. The two groups who received the allergen under their tongues did see a reduction in their exacerbations even when the steroids were reduced and discontinued.

Rick says the benefits to the treatment, abbreviated 'SLIT,' are multiple, and include ease of administration (no one likes shots!) and a reduced dosing schedule over months rather than continuously, as is seen with allergy shots.  Potential downsides include slightly less efficacy relative to injections and some oral itching and associated mouth symptoms in about 20% of the higher dose SLIT group. Do these results warrant expanded investigation into other groups of allergic folks, and perhaps tablets with more than one allergen?  Stay tuned, as we agree that the likelihood seems high.

Other topics this week include 'antibiotic stewardship' and risks of smoking cessation drugs in the Lancet, and methods to reduce Clostridium difficile infection in the hospital in JAMA Internal Medicine. Until next week, y'all live well.

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iStock_000062391332_MediumPeople who have greater economic resources live longer than those who don't, a study published in JAMA that Rick and I discuss on PodMed concludes. This conclusion is certainly rather sobering and is bolstered by a very large amount of data: "Income data for the US population were obtained from 1.4 billion deidentified tax records between 1999 and 2014. Mortality data were obtained from Social Security Administration death records. These data were used to estimate race- and ethnicity-adjusted life expectancy at 40 years of age by household income percentile, sex, and geographic area, and to evaluate factors associated with differences in life expectancy."  Wow.  Rick and I are both impressed and daunted by the shear size of this dataset. Watson, anyone?

The study essentially found that there is a more or less positive relationship between income and longevity, with those who make the most money living longest. This is a trend that is increasing over time, accounts for a greater disparity in the lifetimes of men than women, and varies quite a bit across the nation's geography.  Perhaps most interesting is the fact that access to healthcare did not seem to affect longevity.  The factors that were associated with shortened lifetime included smoking, sedentary lifestyle and poor dietary choices.  We agree that there is ripe fodder for policy change in these conclusions and suspect that's where this study will have the most impact.

Other topics this week include a long term look at the high end of normal BMI and cardiovascular mortality in NEJM, five star ratings of hospitals in JAMA Internal Medicine, and aspirin recommendations in Annals of Internal Medicine.  Until next week, y'all live well.

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