iStock-183991779Wow.  Hard as it is for me to believe, Rick and I focus our attention this week on PodMed on the subject of ear wax, or cerumen, as it's known among the medical tribe.  Why is that?  Because the American Academy of Otolaryngology has published new guidelines on the subject, and it's a lot more impactful (boo!) than we were aware.

Rick points out in the podcast that there are certain groups who are at high risk to have ear wax accumulate and become impacted in the ear canal, including the elderly, small children, those who wear hearing aids and those who live in nursing homes or have dementia. In fact one in ten people may suffer from such a condition. When cerumen becomes impacted hearing can clearly be affected, but a sensation of fullness and even infection can also result. Getting the stuff out is more problematic than you may think; the adage I heard many years ago about never inserting anything larger than your elbow in  your ear is once again invoked.  Cotton tipped swabs may actually make the problem worse and are not recommended.  Folks are advised to see their primary care doc, who can first visualize whether there is a problem, and then use either mechanical means to remove it or chose among several agents to dissolve it. Even this choice may be complicated by whether someone is on a blood thinner or has other medical conditions.  Who knew? Guess we're glad they stepped up to this.

Other topics this week include Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative CareA Randomized Clinical Trial in JAMA Internal Medicine, and two from Annals of Internal Medicine:

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iStock-505980885Asthma is a killer, especially for children. Now a study Rick and I report on PodMed this week and published in the New England Journal of Medicine offers hope for preventing this condition by supplementing pregnant women with fish oil. Novel for sure, and able to reduce the incidence of asthma and wheezing in offspring by an impressive 30%+.  What exactly did they do?

First off it must be admitted that the study took place in Denmark, one of the places in the world where a robust and trusted healthcare system could identify, recruit, supplement women during pregnancy and track offspring for a few years after their birth.  Moreover Denmark may have been one of the few places where the a priori hypothesis that reduced consumption of omega-3 fatty acids and the observed increase in asthma and wheezing in children were related.  In any case, 736 women recruited to the study were randomly assigned to receive 2.4 grams of fish oil per day or olive oil, beginning at 24 weeks of gestation. Their children were followed for three years after birth. In short, the study found that supplementation resulted in a one-third reduction of wheezing, asthma, and upper respiratory infections among those children whose mothers took fish oil. As Rick and I comment, seems like a reasonable strategy to employ right now in all pregnant women, as the downside is almost nonexistent while the potential upside sizable.

Other topics this week include two from Annals of Internal Medicine:Readmission Rates After Passage of the Hospital Readmissions Reduction ProgramA Pre–Post Analysis and The Scientific Basis of Guideline Recommendations on Sugar IntakeA Systematic Review, and from JAMA US Spending on Personal Health Care and Public Health, 1996-2013.  Happy New Year, and y'all live well.

 

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iStock-510952418Imagine having an EEG to look at brain activity when assessing choices of underwear, specifically with regard to color.  Hmmm.  Sounds like a bunch of people, both investigators and study participants, with too much time on their hands, but there it is.  As Rick and I discuss on PodMed this week and published in the Australasian Marketing Journal (!), researchers asked 20 subjects to evaluate underwear that was red, white, blue, brown, grey or black while having a 6 channel EEG. Brain wave activity was collected from frontal, temporal, and occipital lobes, with results demonstrating a clear bilateral change in all three lobes when the subject indicated their preferred color. Most interestingly and informative for the Christmas season, women preferred red undergarments while men preferred white. Rick refers to this phenomenon as 'tighty whities' and we both agree that men who are buying their female partners underwear should take note.

Other fun topics this week include Effects of Mediterranean diet in patients with recurring colds and frequent complicationsStudy of a laboratory-scaled new method for the accelerated continuous ageing of wine spirits by applying ultrasound energy and Use of LED light for Brussels sprouts post harvest conservation. Happy reading, and a Merry Christmas!  Until next week, y'all live well.

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m_joi160106f2Where you live in the United States may have a big impact on how you die, a study Rick and I discuss on PodMed this week and published in JAMA demonstrates. We are both impressed with the shear size of this database as well as the prodigious crunching that had to take place to generate an array of illustrative graphics.  Said graphics depict the map of the United States with death from various causes represented, and illustrate the fact that the southern part of the country suffers a disproportionate amount of cardiovascular disease and death from violence. As Rick points out in the podcast, this is also where risk factors such as smoking, obesity and sedentary lifestyle are prevalent, so perhaps it shouldn't be surprising. He also points out that targeted interventions are both possible and indicated in these areas, so clearly the study is of huge public health importance.

The study in unique in that it actually calculates death rates by county, of which there are over 3000, in the United States, for the 21 most common causes of death. It also attempts to correct for so-called 'garbage codes,' relative to causes of death that don't provide any real information. Interestingly, from the over 80 million deaths that took place during the time period in this study, over 19 million were assigned garbage codes as causes of death.  This points out another public health issue relative to gathering of trustworthy data.  No doubt plenty of initiatives will result from this study, we agree.

Other topics this week include Association Between Statin Exposure and Alzheimer Disease by Sex/Race in JAMA Neurology, Demographic Differences in Adult Use of Psychiatric Drugs in JAMA Neurology, and NIDA statistics on teen substance use and abuse.  Until next week, y'all live well.

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iStock-478561284Parkinson's disease is a very common neurodegenerative disease, affecting over 50 million people worldwide in 2013, recent data estimate. And who among us hasn't seen the shaking hands and shuffling gait typical of this debilitating condition?  The bad news is the relentless progression of the disorder, with depression and dementia frequently developing. Now, as Rick and I discuss on PodMed this week and published in JAMA Neurology, an assay looking at a misfolded protein called alpha-synuclein may help in diagnosis, progression, and perhaps ultimately treatments or cure.  And the study introduces to us a new technique for amplification of small amounts of protein, which we predict will have great clinical utility in lots of conditions.

The novel technology here is called 'protein misfolding cyclic amplification or PMCA,' and it takes advantage of the fact that misfolded proteins such as alpha-synuclein cause additional aberrant protein to form, thus allowing amplification of the signal to a detectable level. PMCA was utilized to detect alpha-synuclein in the cerebrospinal fluid of 76 people with known Parkinson's disease and 65 others with a different neurological disorder. In short, PMCA was 88.5% sensitive and 96.9% specific in identifying those with Parkinson's and was also correlated with symptom severity. As Rick and I also note, it would be great to have something other than CSF to test to render PMCA more practical, but this proof of concept study is heartening.

Other topics this week are all from NEJM: Revascularization of Left Main Coronary Artery DiseaseCrizanlizumab for the Prevention of Pain Crises in Sickle Cell Disease, and Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting. Until next week, y'all live well.

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iStock-489309852People who are frail don't do as well during and after surgery as those who aren't. Duh. Now a study Rick and I discuss on PodMed this week and published in JAMA Surgery attempted to assess frailty preoperatively and develop a plan for afterward, with results that are impressive indeed.

Beginning in October 2007 to July 1, 2014, all patients who came to a single Veteran's Administration medical center for major, elective non-cardiac surgery were assessed preoperatively using a frailty index, and those who were identified as frail comprehensively evaluated by a multidisciplinary team, who created a plan for their care. Here are the results directly from the paper:

Results  From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16).

Rick and I agree that this is impressive indeed, and I am especially impressed by the statement I bolded above, that even among those who weren't deemed to be at risk such an assessment substantially improved outcomes. And among all comers, the results were durable for 180 days.  Sounds like a clear imperative to implement such a strategy globally.

Other topics this week include Accuracy of a Deep Learning Algorithm for Detection of Diabetic RetinopathySwimming, aerobics, and racquet sports are linked to lowest risk of cardiovascular death from the BMJ, and Pronounced increase in risk of acute ST-segment elevation myocardial infarction in younger smokers, from Heart.  Until next week, y'all live well.

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iStock-486792042Watching and waiting may take place too long in the UK when it comes to abdominal aortic aneurysms (AAA), a study Rick and I discuss on PodMed this week and as published in NEJM reveals, since a number of dire outcomes seem to result when repair is delayed until a certain size aneurysm is reached And as I chortle to Rick, it isn't often our interventional approach to many medical conditions is validated when compared to more conservative strategies, so this study is noteworthy to me in that regard.

Data from almost 30,000 folks who underwent AAA repair in the UK was compared in this study to almost 280,000 records from those with the same condition in the US. This was during the time period from 2005 through 2012. The impact of the higher thresholds for treatment in the UK was examined through the lens of three outcomes: death relative to the aneurysm, hospitalization relative to AAA, and likelihood of repair. The study found that AAA repair was less likely to be undertaken in the UK, that aneurysm-related death was almost four times more likely in the UK, and that hospitalization due to rupture was more than twice as likely across the pond. The average threshold for treatment was 58.3 millimeters domestically versus 63.1mm in the UK. Hmmm.  Seems like operating sooner rather than later is a better strategy, and Rick and I also note that screening, especially for older men who are current or former smokers, is also important.

Other topics this week include Symptoms and Satisfaction of Patients in the PROWL StudiesHip and Pelvic Fracture Risk Associated With Antihypertensive Medications, and a look a mumps in the US currently from MMWR http://www.cdc.gov/mmwr/index.html, along with measles surveillance.  Until next week, y'all live well.

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Neck-PainPain relief is an important part of maintaining quality of life for many, including me, so NSAIDs, non-steroidal anti-inflammatory medicines, are welcome.  But many studies have rumbled that they may be risky for your heart.  Good news then, as Rick and I discuss on PodMed this week and as published online in NEJM, at least three of them appear NOT to confer increased risk for cardiovascular events, at least in comparison to each other and with certain other caveats.  This as also revealed at the recently concluded American Heart Association meeting.

People who took part in this trial had either osteo- or rheumatoid arthritis and were randomized to either celecoxib (Celebrex), ibuprofen or naproxen at various doses daily. Just over 24,000 subjects were treated for about two years and followed for almost three. Almost 70% of participants stopped taking their drug and just over 27% discontinued follow-up. When looking for the three primary outcomes of cardiovascular death, nonfatal heart attack or stroke, no significant difference was found between the three groups, with about 2.5% experiencing such an event. Additional assessments were also made with regard to renal and gastrointestinal problems, with celecoxib emerging as the least risky.

Rick concludes from this study that at the low doses employed here, and for short duration, celecoxib appears to be safe, but we'd both like to see a more pragmatic trial with higher doses and longer treatment periods. Other topics this week include Randomized Trial of Bilateral versus Single Internal-Thoracic-Artery GraftsGenetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease, and A Highly Durable RNAi Therapeutic Inhibitor of PCSK9. Until next week, y'all live well.

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iStock_80130559_SMALLLazy eye, or amblyopia in medical parlance, affects a surprisingly large number of kids: about 3%! We've probably all seen a child who is being treated for the disorder, with one eye patched so the other is forced to behave in a more functional manner.  Patching has been the standard of treatment for quite some time, but outcomes aren't always quite as good as hoped for, even after prolonged periods of treatment. And even when successfully treated, recurrence is common. Enter then a study in JAMA Ophthalmology Rick and I discuss on PodMed this week: use of iPad games to treat lazy eye, with uplifting results.

Researchers identified 28 children with amblyopia, average age 6.7 years, and randomized them to either an eye patch or to use of an iPad loaded with a game that required binocular vision. They needed to play the game for an hour daily for five days each week. As Rick points out in the podcast, this game was very carefully tailored to appeal to children in this age group. After two weeks of gaming, children in the iPad group had improved more than those in the patch group.  At this point all children were offered the iPad and at four weeks, both groups had experienced the same improvement.  Rick and I both agree that such a strategy seems very attractive and seems likely to be successful at scale up.  We agree with the study authors that longer term follow-up as well as relapse treatment are important, and look forward to seeing more (no pun intended).

Other topics this week include Association Between Intensity of Statin Therapy and Mortality in Patients With Atherosclerotic Cardiovascular Disease in JAMA Cardiology, a new cardiovascular risk prediction tool: http://circ.ahajournals.org/content/early/2016/11/03/CIR.0000000000000467, and Pembrolizumab as Initial Treatment in Lung Cancer in NEJM.  Until next week, y'all live well.

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iStock_000016798528_MediumHeart disease remains the number one killer of people worldwide, and if you've done any looking around in public places like airports you've probably noticed devices prominently displayed that say "AED" for automated external defibrillator. These devices are potentially lifesaving for folks who suffer a certain type of heart attack in public, where someone has the presence of mind to utilize one.  Just how often does that happen and what are the outcomes?  That's one of the studies Rick and I discuss on PodMed this week, as published in the New England Journal of Medicine.

The statistics in this article are so impressive: "Of 43,762 patients with bystander-witnessed ventricular-fibrillation arrests of cardiac origin, 4499 (10.3%) received public-access defibrillation."  The study took place in Japan, one of the countries where such data are available, accessing information gathered between 2005 to 2013.  The primary outcome assessed was survival at one month with a favorable neurological outcome, and not surprisingly, showed that almost 39% of those who were defibrillated by a bystander using the device had a favorable outcome compared with just over 18% of those who did not have an AED deployed on their behalf. That's impressive in my opinion, and lends credence to the idea that both use of AEDs as well as bystander initiated CPR could save lives.  Rick points out though that only ventricular fibrillation would benefit here, and that the majority of such events take place in the home, when neither bystander nor AED are most often available.

Other topics this week, all from NEJM, include Effect of Short-Term vs. Long-Term Blood Storage on Mortality after TransfusionFive-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting and Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. Until next week, y'all live well.

 

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