GettyImages_464671264Should you begin exposing your infant to peanuts very early in life?  The answer may well be yes, even and especially if your baby is at risk to develop peanut allergy, a study Rick and I examine on PodMed this week  and published in the New England Journal of Medicine concludes.  How can babies at risk to develop peanut allergy be identified?  Turns out if they have the skin rash known as eczema, or have siblings or parents with the condition, this can be predictive.  Clearly parents will want to know about risk before exposing their infants, and skin testing may also help.  Finally, we conclude that peanut butter rather than whole peanuts may be the right vehicle, and Rick suggests that parents may want to attempt this in a physician's office so help is available if the baby has a reaction.  Since this is such a big and growing problem, seems like an 80% reduction in development of the condition is well worth attempting.

Other topics this week include pregnancy after bariatric surgery in the same journal, a report from the CDC and other federal agencies on common bugs and foods that cause food borne illness, and the risk of NSAIDs in those who've had a heart attack in JAMA.  Until next week, y'all live well.

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459903291Are electric fans any help in the prevention of overheating?  Rick and I consider that 'hot' topic this week on PodMed, and for me as well as my colleagues here in Baltimore, thinking of hot things is a welcome respite from the Arctic conditions outside!  The study is a small one published in JAMA, but shows that up to certain levels of humidity fans indeed help reduce increases in core temperature and sweating in subjects exposed to heat and humidity.  Surprisingly, this runs counter to the current public health notion that fans aren't helpful in these circumstances and may in fact be harmful.  Hmmm, as I opine in the podcast, good to have a cheaper alternative to AC or going to a shelter.

Other topics this week include steroid use in pneumonia and varenecline use in people who have doubts about quitting smoking, both in JAMA, and Fusobacterium as a common cause of sore throats in a group of teenagers and young adults, in Annals of Internal Medicine.  Until next week, y'all live well.

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200570995-001If you want to improve your health, even if you're an avid exerciser, you need to avoid sitting for prolonged periods of time, Rick and I discuss on PodMed this week.  That's according to a study in Annals of Internal Medicine, where irrespective of whether regular exercise was a part of the regimen, those who sat for prolonged periods experienced greater all-cause mortality as well as that from specific diseases.  Rick offers a number of practical ideas for getting moving in the workplace, which is, of course, where most of us spend a lot of time at the desk.

Other topics this week include a lack of benefit seen with bathing patients in the ICU with chlorhexidine daily, exciting results from an uncontrolled trial using stem cells in folks with multiple sclerosis, and lackluster results from intracytoplasmic sperm injection versus standard techniques for infertility. Until next week, y'all live well.

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When the whole community gets involved, people can reduce their risk factors for heart disease, reduce hospitalizations and live longer, Rick and I report on PodMed this week.  That's from a study published in JAMA.  Also in that journal, a look at breast cancer mortality as it relates to ethnicity, and in JAMA Internal Medicine, two studies: too much aspirin use and overtreatment of diabetes in older folks.  Until next week, y'all live well.

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thCAQZ6PWHWelcome to our annual Christmas spoof!  Happy listening, and a safe and healthy new year from us both! Three of four in the BMJ, with the fourth from the Journal of Economic Behavior And Organization.

http://podcasts.hopkinsmedicine.org/2014/12/19/podmed-week-of-december-22-2014/

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89468358PD-1 is a cancer pathway that's been known for some time to the cognoscenti.  On PodMed this week, Rick and I talk about a study in NEJM, which is incidentally where all the studies we talk about this week are published, that appears to bring manipulation of this pathway to fruition in folks with Hodgkin's lymphoma. Good news indeed, as well as proof of concept.  What did they do? First, a little background is appropriate.

PD-1, in that often inscrutable scientific fashion that is happily absent here when it comes to naming, stands for programmed death.  In this case it refers to a way our bodies use to damp down an immune response by T cells, one of the army of cells mobilized to protect us but which need to be called off when the deed is done. We can think of PD-1 as running up the surrender flag so T cells chill out.  Turns out cancer cells do the same, running up the surrender flag to call off T cells that might otherwise attack and kill them.  Oh so clever cancer cells!  This property partially explains why our immune systems fail to recognize these invaders and dispatch them, and it's also something researchers have been struggling to exploit for some time.  Indeed, antibodies to manipulate this pathway have been developed and used clinically, with this study reporting such an antibody for Hodgkin's.

Hodgkin's, of course, is rather a curiosity when it comes to immune system manipulation.  The problematic cells in the disease known as 'Reed-Sternberg cells' actually reside within a veritable army of immune cells, yet somehow evade detection and destruction. PD-1 utilization is alive and well in this type of cancer, and the authors reveal that host infection with Epstein-Barr virus also up-regulates this mechanism. Accordingly, 23 patients with Hodgkin's lymphoma who had either relapsed or had refractory disease were enrolled in this study to receive the monoclonal antibody 'nivolumab.' Previous treatment of these folks included some pretty heavy hitting therapy: stem cell transplantation and an antibody 'brentuximab vedotin.'

Here's the good news: "An objective response was reported in 20 patients (87%), including 17% with a complete response and 70% with a partial response; the remaining 3 patients (13%) had stable disease."  Wow!  That's very impressive.  Side effects could be problematic with nivolumab: "Overall, drug-related adverse events were reported in 18 patients (78%). The most common were rash (in 22%) and a decreased platelet count (in 17%). Drug-related grade 3 adverse events, which were reported in 5 patients (22%), included the myelodysplastic syndrome, pancreatitis, pneumonitis, stomatitis, colitis, gastrointestinal inflammation, thrombocytopenia, an increased lipase level, a decreased lymphocyte level, and leukopenia." These drug effects were manageable and the authors conclude that inhibition of the PD-1 pathway may be a very important therapeutic target in patients with this disease, and we agree.  Rick also opines that examination of additional tumor types will likely result in more applications for this strategy.

Other topics this week include the use of progesterone in traumatic brain injury, a new type of blood thinner, and US healthcare and equality, as mentioned before, all in NEJM.  Until next week, y'all live well.

 

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522780939How would you characterize your typical diet?  Fast food heavy, dining out, carb loading?  Now a new study Rick and I discuss on PodMed this week provides further support that we might all benefit from adoption of the so-called 'Mediterranean diet,' as published in the BMJ. That's the conclusion at least if you're persuaded by the life-preserving capabilities of telomeres, those protective ends of chromosomes that shorten as we age.  Huh? How's telomere length related to diet?  Let's take a look at the study.

Researchers looked at data from the Nurses Health Study, specifically from almost 4700 of the 121,700 original enrollees, all female registered nurses who began the study in 1976.  This analysis relies on a group selected because they were free of major chronic diseases, including cardiovascular disease and cancer, having been identified as healthy controls in other analyses of this data set, had completed food questionnaires, and had had their white blood cells analyzed for telomere length.

So what about this diet?  While the traditional Mediterranean diet is described as having a" high intake of vegetables, fruits, nuts, legumes, and grains (mainly unrefined); a high intake of olive oil but a low intake of saturated lipids; a moderately high intake of fish; a low intake of dairy products, meat, and poultry; and a regular but moderate intake of alcohol (specifically wine with meals)" the questionnaire utilized in this study gave point values to each component of the diet in what is called the 'Alternate Mediterranean diet score.' The score allowed quantitation of each additional dietary choice. Additional dietary analyses were also employed.

What about those telomeres?  As Nobel Prize recipient Carol Greider, our colleague here at Johns Hopkins describes, telomeres are like those little plastic tips on the ends of shoelaces.  As time goes on these get shorter and shorter, with short telomeres associated with cancer, some autoimmune diseases, and aging.  Nurses enrolled in this study had their telomere length assessed just once.  This was correlated with their diet score, and lo and behold! Those women who reported greater adherence to a Mediterranean diet also had longer telomeres, and the relationship was dose-response; the more adherent a woman was the longer her telomeres were.

Potential confounders were also considered in this study, with women who had higher adherence to the Mediterranean diet also smoking less, exercising more, weighing less, and also being slightly older at the time their blood was drawn. Still, the authors conclude that the study provides more evidence for the potential benefit of adopting a more Mediterranean-style diet.  Since we like that kind of food, Rick and I are happy to do so, but we're still waiting for the smoking gun with regard to the exact relationship between telomeres, aging and disease.

Other topics this week include unsafe infant sleeping practices in Pediatrics, circumcision recommendations from the CDC, and taking asthma drugs daily or only as needed in the Lancet.  Until next week, y'all live well.

 

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474037137When was the last time you consumed a school lunch?  As Rick and I quip on PodMed this week, we have a collective and not-so-fond memory of 'mystery meat' and the like. Things have changed quite a bit these days, a study on the nutritional value of home-packed versus school-provided lunches as published in JAMA Pediatrics demonstrates, and while we're at it, seems like breakfast at school is another good idea, per a second study in the same issue.

The lunch study examined the nutritional content of lunches from home of 242 elementary and 95 intermediate school students from 12 schools located in the Houston, TX, area. The content of these lunches was compared with the guidelines found in the National School Lunch Program, begun in 2012, based on a 2009 (!) Institute of Medicine report.  I'll leave this huge legislative delay alone for the moment, and note that these were the first updates to nutritional recommendations for children for more than 30 years.

Here's what the study determined, "Compared with the NSLP guidelines, lunches brought from home contained more sodium (1110 vs ≤640 mg for elementary and 1003 vs ≤710 mg for intermediate students) and fewer servings of fruits (0.33 cup for elementary and 0.29 cup for intermediate students vs 0.50 cup per the NSLP guidelines), vegetables (0.07 cup for elementary and 0.11 cup for intermediate students vs 0.75 cup per the NSLP guidelines), whole grains (0.22-oz equivalent for elementary and 0.31-oz equivalent for intermediate students vs 0.50-oz minimum per the NLSP guidelines), and fluid milk (0.08 cup for elementary and 0.02 cup for intermediate students vs 1 cup per the NSLP guidelines). About 90% of lunches from home contained desserts, snack chips, and sweetened beverages, which are not permitted in reimbursable school meals. The cost of lunches from home averaged $1.93 for elementary and $1.76 for intermediate students. Students from lower-income intermediate schools brought significantly higher-priced ($1.94) lunches than did students from middle-income schools ($1.63)." While the authors conclude that efforts should be undertaken to educate parents to pack more nutritional lunches, we take a slightly different tack and opine that perhaps all children should be encouraged to eat school-provided lunches.

Ditto for the breakfast study.  Turns out that while school breakfast programs have been in place for some time in many low income areas, barriers to children actually eating breakfast at school include the need to arrive early as well as stigma associated with the program.  This study looked at 446 public elementary schools and assessed the impact of serving breakfast in the classroom.  While the authors were aiming at whether such a strategy improved academic performance this outcome was not significant, which Rick considers not surprising as the study wasn't long enough. Things that did show immediate improvement were the number of children who benefited, reductions in tardiness and improvements in overall attendance. I suggest in the podcast a sliding scale for all parents, so that all children can have breakfast in the classroom.  There is abundant evidence for the benefits of breakfast on school performance, and such a strategy would reduce stigma.  While we're at it, why not include lunch, too?

Other topics this week include two new agents to reduce potassium levels in people with chronic kidney disease in NEJM, a new agent for treating chronic cough in the Lancet, and two medications for managing Marfan syndrome in NEJM.  Until next week, y'all live well.

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450642795Man or machine?  This debate increasingly occurs in many venues as computers and other devices created for our convenience, comfort and ease continue to be invented and disseminated.  But there's one area where the machine remains inferior to the efforts of man, as Rick and I discuss on PodMed this week: CPR or cardiopulmonary resuscitation. That's as featured in the Lancet this week and also presented at the American Heart Association meeting taking place concurrently.

This trial is unique in that it is pragmatic.  Rather than being conducted under ideal clinical or laboratory conditions, instead this trial randomized actual patients who had experienced out-of-hospital myocardial infarction (MI) or heart attack being transported from the field via ambulance.  The subjects were randomized in a 1:2 ration, respectively, to either mechanical CPR using a device known as a LUCAS-2, or manual CPR. A total of 4471 subjects who experienced cardiac arrest not as a result of trauma were included, with randomization taking place depending on which response vehicle arrived on the scene first, one equipped with the mechanical device or not. Sixty percent of those in the mechanical group actually received CPR using the device while 11 (less than 1%) of the manual group did so.

The primary outcome was survival at 30 days post-MI, with secondary outcomes event survival, survival to 3 months, survival to 12 months, and survival with favorable neurological outcome at 3 months. Clearly the favorable neurological data is very important as this is compromised in many survivors.

There was no significant difference in 30 day survival among those who received mechanical CPR versus those who received manual: 6% versus 7% respectively. Longer term survival was also similar between groups, but those who received mechanical CPR had worse neurological outcomes than those who had manual CPR. A low rate of adverse events was also seen in those treated with the LUCAS-2:  three patients with chest bruising, two with chest lacerations, and two with blood in mouth. 15 device incidents while the LUCAS-2 was employed.

The authors conclude, and we agree, that the results of this trial argue against use of mechanical devices to perform CPR.  They're expensive, personnel using them require training, and they don't achieve the desired objective of improving survival odds for those having an out-of-hospital cardiac arrest.  Since almost half a million such events occur each year in the US alone, getting our arms around the best way to conduct CPR is clearly important.  Rick and I agree that we're glad this study was done.  In a real world environment, under conditions where the expectation would be that the machine would perform better while jostling around in the back of an ambulance, it didn't.  Yet one more example of assumptions disproved, so kudos to the authors.

Rick makes the point that out-of-hospital CPR is very simple, consisting of chest compressions only, and that more efforts need to undertaken to simply convince the public that they're the best chance someone who's experienced an MI has to make it alive to the hospital.  Other topics this week on our heart-only issue include a better understanding of HDL cholesterol in NEJM, appropriate duration of dual antiplatelet therapy after stenting in the same journal, and police work and sudden cardiac death in the BMJ.  Until next week, y'all live well.

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86496585When confronted with the reality of death, the majority of people asked about their preferences say they'd like to die at home, surrounded by friends and family, and with minimal pain and discomfort.  Yet the sad fact remains that many people are unable to achieve that goal, Rick and I discuss on PodMed this week,  in spite of abundantly available hospice services.What are the barriers to more widespread utilization of hospice and can a cost analysis help provide evidence that such services are not only humane but cost-effective?  That's the substance of a study published this week in JAMA.

Researchers crunched numbers from a  20% sample of Medicare fee-for-service beneficiaries who died in 2011, all with a cancer diagnosis. Patients with brain, pancreatic, metastatic malignancies or other poor-prognosis cancers enrolled in hospice before death were matched to similar patients who died without hospice care, resulting in almost 87,000 enrollee records for the analysis, about 60% of whom were enrolled in hospice care at the end of life. The final cohort consisted of 18,165 patients with poor prognosis cancers who were enrolled in hospice and the same number who were not, matched on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization.

Here's what the analysis showed: "After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. After exposure, nonhospice beneficiaries had significantly more hospitalizations (65% [95% CI, 64%-66%], vs hospice with 42% [95% CI, 42%-43%]; risk ratio, 1.5 [95% CI, 1.5-1.6]), intensive care (36% [95% CI, 35%-37%], vs hospice with 15% [95% CI, 14%-15%]; risk ratio, 2.4 [95% CI, 2.3-2.5]), and invasive procedures (51% [95% CI, 50%-52%], vs hospice with 27% [95% CI, 26%-27%]; risk ratio, 1.9 [95% CI, 1.9-2.0]), largely for acute conditions not directly related to cancer; and 74% (95% CI, 74%-75%) of nonhospice beneficiaries died in hospitals and nursing facilities compared with 14% (95% CI, 14%-15%) of hospice beneficiaries. Costs for hospice and nonhospice beneficiaries were not significantly different at baseline, but diverged after hospice start. Total costs over the last year of life were $71 517 (95% CI, $70 543-72 490) for nonhospice and $62 819 (95% CI, $62 082-63 557) for hospice, a statistically significant difference of $8697 (95% CI, $7560-$9835)."  Wow.  That's a lot of resources saved at the end of life, and as I query Rick in the podcast, wonder what would have happened if hospice had been utilized sooner than the median of 11 days found in this study?

It's revealing to look at what the authors consider to be major barriers to more hospice utilization.  They cite the penalty exacted by the Medicare administration against hospices with extended hospice stays, current lack of reimbursement for end-of-life discussions to physicians by the same agency, and finally, the requirement that patients forego any treatment with a curative intent in order to enroll as all having a chilling effect on enthusiasm for earlier adoption of hospice services.  Yet at least one myth, that of potential increased costs relative to hospice care, is clearly dispelled by this study.  Our hope is that the evidence provided here will help inform discussion around overcoming barriers and toward adoption of a more compassionate model of medical care at the end of life.

Other topics this week include Ebola treatment of two patients here in the US in NEJM, Tdap vaccination during pregnancy in JAMA, and four popular weight loss diets compared in Circulation.  Until next week, y'all live well.

 

 

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