iStock_000073325415_MediumOkay, so I admit it.  Sometimes Rick picks something for PodMed I shake my head about, and this study, published in NEJM, was one of them.  What's the broad applicability of the choice of topical agents to disinfect the skin previous to an incision in women about to undergo C-section? Here's what's great about my job: I continuously have the opportunity to become educated, and this is a stellar example.  Turns out that choosing a chlorhexidine-based agent rather than an iodine-based one results in about half the number of skin infections in women who have this operation.  And since the average cost of treating such an infection is about $3500, that's a significant savings, let alone avoiding interruption in care to the infant and morbidity for the mom.

This single site study randomized over 1100 women to use of chlorhexidine or iodine based solutions for skin swabbing prior to Cesarean section.  Nationally this population alone is significant; C-section is the most common surgical procedure among US women, with more than 1.3 million taking place in 2013. Reducing infections is obviously a great outcome, and Rick and I agree that as results of this study are promulgated, use of chlorhexidine-based scrubs will no doubt be employed in many other procedures.

Other topics this week include relaxing surgical resident work hours, also in NEJM, and update on Zika virus, and questionable trial results for rivaroxaban in the BMJ.  Until next week, y'all live well.

 

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iStock_000068289239_MediumMany people really aren't interested in having screening colonoscopy, even though the procedure has been shown to catch many cases of colorectal cancer as well as precancerous polyps early, so treatment is facilitated and survival improves.  But now a study Rick and I discuss on PodMed this week and published in Annals of Internal Medicine demonstrates the utility of a mail-in fecal sample to perform initial screening for colorectal cancer in a large group of adults, with impressive results.  As I quip in the podcast, here's a potential role for the United States Postal Service in health care!

Over 300,000 people fifty to seventy years of age were offered initial screening using fecal immunochemical testing (FIT), using a mail-in card with a self-collected fecal specimen.  The majority remained in the program for up to four subsequent rounds for up to four years of follow-up.  The technique was able to detect just over 80% of those with colorectal cancer after the first round of screening, with slightly reduced detection rates in subsequent rounds. Rick and I opine that over the years we've seen detection improve with fecal specimens and different techniques, and predict that trajectory will continue, rendering such a method for screening much less invasive, expensive and time-consuming for all concerned.  Taken together with another study we discussed this week in JAMA Internal Medicine on mailed nicotine patches and their efficacy in helping smoking cessation, the US Postal Service might stay afloat!

The other two studies we discuss this week are in JAMA: the USPSTF guidelines on depression screening, and malpractice claims in NEJM.  until next week, y'all live well.

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iStock_000062992601_MediumYou've no doubt heard by now of our latest mosquito-borne scourge: Zika virus.  Rick and I discuss what's known so far on PodMed this week, per a Centers for Disease Control and Prevention alert.  And even as we ponder nomenclature for emerging viruses we also wonder at where the critters are hiding before they come to our awareness, and wreak havoc on fetuses of women who have the ill fortune to become infected. What do we know so far?

Zika virus is transmitted by our friend the Aedes aegypti mosquito, which is also credited with transmission of dengue and chikungunya.  The bug bites day or night, and the best protections include staying indoors in the AC or screened-in places, long sleeves and pants, repellent use and so on.  For women who are pregnant the agency recommends against travel to any area where the infection is active, and notes that women can be infected at any stage of pregnancy.  Pregnant or not, about 80% of those who are infected are asymptomatic, and even those who with symptoms experience nonspecific ones.  Thus the CDC recommends that any pregnant woman who has traveled to these areas be screened for possible Zika virus infection, with ultrasonography for follow up in order to detect microcephaly or intracranial calcifications. No doubt we'll all learn more as the medical sleuths get underway.

Other topics this week include PT and Parkinson's disease in JAMA Neurology, afib in women in the BMJ, and a theme issue on oncology end of life issues in JAMA.  Until next week, y'all live well.

 

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Probiotic pills conceptCan probiotics help stave off the development of type 1 diabetes in infants at risk to develop the condition?  In a provocative study in this week's JAMA Pediatrics Rick and I talk about on PodMed  this week, the answer seems to be yes, at least in those with a specific mutation. Researchers gathered data from almost 7500 children at risk to develop type 1 diabetes from six clinical centers, three in the US and three in Europe.  Blood samples to assess antibody development to islet cells of the pancreas, one target of autoimmunity in the disease, were collected every 3 months when the children were between 3 and 48 months of age and then every six months thereafter. The cohort was stratified with regard to consumption of probiotics as this is common practice in Europe but not in the US. The data showed that those children who had one genotype, called DR3/4, and who consumed probiotics were at a greater than 60% reduced risk for developing diabetes compared to those not exposed but who had the same genotype. Pretty powerful stuff, in my mind, and well worth assessing in a prospective, randomized fashion. Now for finding an effective intervention for all those other at risk!

Other topics this week include a JAMA study showing that one-third of adult cancers may be due to inherited genes, JAMA Pediatrics on influencing food choices in middle and high school students, and the true value of cancer screening tests in the BMJ.  Until next week, y'all live well.

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iStock_000022047429_MediumChronic lymphocytic leukemia, abbreviated CLL in medical parlance, may have met its match with a new drug described in NEJM that Rick and I discuss on PodMed this week.  And since CLL affects mostly older individuals, a burgeoning population both domestically and globally, this is good news indeed.

The drug is called ibrutinib, and it is the first-in-class inhibitor of an enzyme known as Bruton's tyrosine kinase. The enzyme is known to be essential in survival and proliferation of immune cells gone awry in this type of blood cancer. Previous studies utilized ibrutinib along with other agents in people who had relapsed, or as primary therapy in patients having a specific genetic abnormality. This study used the drug in older, previously untreated patients. A total of 269 treatment naive subjects with CLL were randomized to either ibrutinib or chlorambucil. Improvements were seen in progression-free survival, overall survival, response rate, and hematologic variables.  Additionally, the oral agent was well-tolerated and associated with relatively mild side effects, including nausea, cough, diarrhea and fatigue, with 87% of patients in the ibrutinib group continuing to take the medication. Bill Nelson, director of the Kimmel Cancer Center at Johns Hopkins, calls this study practice-changing, and Rick points out in the podcast that among this group of people, who frequently have at least one other medical condition, the arrival of an effective agent with few side effects is terrific.

Other topics this week include CDC recommendations of opioid prescribing, a failure to counsel young women who are taking drugs associated with fetal malformations about contraception in Pediatrics, and use of electric fields in glioblastoma treatment in JAMA. Until next week, y'all live well.

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iStock_000061359348_MediumDoes being generally unhappy make you more likely to die?  Many people, ranging from new age types to medical professionals, have extolled the virtues of a positive outlook on improving health outcomes to actually  avoiding developing health problems in the first place. Indeed, our culture of happiness is so entrenched that some studies have reported cancer patients feeling guilty about their negative stance on life and its impact on their disease.  Now, as Rick and I discuss on PodMed this week and as published in the Lancet, comes a study that seems to dispel this relationship.

This investigation was part of the UK Million Women Study. Subjects were queried on feelings of stress, control. relaxation, health, and happiness.  One in six reported unhappiness, with smoking, lack of exercise, not living with a partner, and poor health associated with unhappiness.  Ten years later, after correcting for the lifestyle and health factors that were already present, the death rate for those who rated themselves unhappy was the same as that for those who identified as happy. Researchers explain this finding as a failure of previous studies to account for the impact on poor health on happiness.  As for Rick and me, we're adopting the mien 'don't worry, be happy' for 2016.  Other topics this week include too much measurement of hemoglobin A1c in those with type 2 diabetes in the BMJ, androgen deprivation and dementia risk in JCO, and a new drug for sickle cell disease in NEJM.  Until next week, y'all live well.

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78606771_thumbnailAre you familiar with PrEP, that strategy for treating people at risk for becoming HIV infected by using a combination medication marketed as Truvada? If you're like one-third of primary health care providers nationally, the answer is no, recent CDC data reveal.  And now, based on a study in NEJM Rick and I discuss on PodMed this week, it's even more critical that those at risk are offered the strategy.  That's because PrEP, which was proven successful in preventing acquisition of the virus in those at risk when taken on a daily basis, has now been shown to be effective when taken PRN.  Wow!  Not only does this make things more palatable for patients, it is also way less expensive.  This last is one of the primary barriers to use of PrEP among those offered the therapy.

The study results were as follows: "Of the 414 participants who underwent randomization, 400 who did not have HIV infection were enrolled (199 in the TDF-FTC group and 201 in the placebo group). All participants were followed for a median of 9.3 months (interquartile range, 4.9 to 20.6). A total of 16 HIV-1 infections occurred during follow-up, 2 in the TDF-FTC group (incidence, 0.91 per 100 person-years) and 14 in the placebo group (incidence, 6.60 per 100 person-years), a relative reduction in the TDF-FTC group of 86% (95% confidence interval, 40 to 98; P=0.002). Participants took a median of 15 pills of TDF-FTC or placebo per month (P=0.57). The rates of serious adverse events were similar in the two study groups. In the TDF-FTC group, as compared with the placebo group, there were higher rates of gastrointestinal adverse events (14% vs. 5%, P=0.002) and renal adverse events (18% vs. 10%, P=0.03)."

Well.  As Joseph Cofrancesco, an HIV expert at Johns Hopkins, has stated to me on multiple occasions, we have the power to stop this epidemic.  Now for the education, awareness, and political will to do so.  Other topics this week include two in JAMA: appropriate rate of C-section and how to manage obstructive sleep apnea, and in the BMJ, a critical look at methylphenidate in those with ADHD.  Until next week, y'all live well.

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iStock_000053775120_MediumIncreasing rates of Alzheimer disease (AD) threaten to overwhelm our health care system domestically and worldwide, but exactly what causes the condition remains controversial, as does diagnosis and monitoring.  Now a study in JAMA Neurology Rick and I discuss on PodMed this week adds more to our understanding of the pathology of AD in perhaps pointing the way toward monitoring more effectively.  Researchers recruited more than 500 'cognitively normal' people enrolled in the Mayo Clinic Study of Aging, median age 78 years.  Each of them had undergone a number of imaging studies, including MRI and two types of PET scanning as well as cognitive assessment. The data analyzed in this study were collected between January 2006 to January 2014.

A positive relationship between increasing amyloid levels and cognitive decline emerged, with those individuals having evidence of more amyloid accumulation more cognitively impaired.  In these same folks reduced hippocampal volume, slower metabolism of FDG-PET, and enlargement of the ventricles of the brain were also observed. These associations were independent of APOE4 carrier status.

The results clearly suggests means of monitoring those at risk for AD, although many of these studies are expensive and seem unlikely to provide a practical means of screening.  Rick points out that we still don't know whether amyloid causes AD or is simply a bystander, but we're both hopeful that studies underway attempting to reduce amyloid and examine impact on the development of AD will shed some light. Other topics this week include ACP recommendations on generic prescription in Annals of Internal Medicine, increasing colorectal cancer screening rates in Cancer, and folic acid supplementation and neural tube defects in the BMJ.  Until next week, y'all live well.

 

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iStock_000042347626_MediumCoffee lovers among us, and I count myself one of them, rejoice!  That's the substance of a study published in Circulation this week that Rick and I feature on PodMed, and the upshot is simple: coffee drinkers live longer.  Rick is of course quick to point out that this is merely an association and therefore does not prove causality, but as for me and my habits, this is one addiction I plan to continue.

What exactly did they do in this study? Researchers crunched numbers from the Nurses Health Study, the Health Professionals Follow-Up Study, and the second iteration of the Nurses Health Study, looking at consumption of coffee, including caffeinated and non-caffeinated varieties, as well as all cause and cause specific mortality.  They found that coffee consumption of from one to five cups per day was inversely related to mortality, whether that beverage contained caffeine or not.  Cause specific mortality also demonstrated an inverse relationship, including death from cardiovascular disease, neurological disease, or suicide. There was no association found between cancer risk and coffee consumption.

Other topics this week include measuring body temperature in Annals of Internal Medicine, and two from NEJM: an oral treatment for respiratory syncytial virus and germ  line mutations and cancer in kids.  Until next week, y'all live well.

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iStock_000017116914_MediumBelly fat is some pretty deadly stuff, Rick and I discuss on PodMed this week, based on a study in Annals of Internal Medicine.  Turns out that even if you have a normal body mass index or BMI, but you're carrying a doughnut around your waist, you're at significantly higher risk for death than either your normal weight counterparts without belly fat, or even those categorized as overweight or obese, but with a more distributed fat pattern.  And that's true for both men and women.

This analysis relied on data from the third NHANES study of more than 15,000 participants, and the findings are concerning.  As we speculate in the podcast, for someone with a normal weight it might be a bit of a tough sell to advocate for weight loss, especially given the well known fact that 'spot reduction' isn't a reality.  It's not really possible to simply lose fat from one's belly.  Rick says from a clinical standpoint, such a fat distribution pattern should be a clear signal to health care providers that interventions to make sure blood pressure and blood sugar are controlled and regular exercise undertaken are take-homes. We both agree that further research into the why of this body fat pattern as well as the mechanism by which it increases risk would be helpful.

Other topics this week include continuous versus intermittent CPR and intensive versus standard blood pressure control in NEJM, and the safety of silicone breast implants in Annals of Internal Medicine.  Until next week, y'all live well.

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