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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iStock_000067787695_MediumWhen you think of Chinese food it's a likely bet you don't think of fresh fruit, as Rick quips on PodMed this week.  That's per a study we discuss in the New England Journal of Medicine on the impact of fresh fruit consumption among a very large cohort of Chinese people living in China on cardiovascular health. Here is the rather amazing description of the study population from the article: "Between 2004 and 2008, we recruited 512,891 adults, 30 to 79 years of age, from 10 diverse localities in China. During 3.2 million person-years of follow-up, 5173 deaths from cardiovascular disease, 2551 incident major coronary events (fatal or nonfatal), 14,579 ischemic strokes, and 3523 intracerebral hemorrhages were recorded among the 451,665 participants who did not have a history of cardiovascular disease or antihypertensive treatments at baseline." Wow. That's a lot of follow up.  The researchers discerned an inverse relationship between fresh fruit consumption and cardiovascular events, even though those folks who consumed more fruit also had higher BMIs and greater central obesity.  Paradoxical much?

It's tempting to simply ascribe the benefits of fruit as protective as so many studies have concluded with regard to fresh foods, but Rick also points out that the Chinese diet is very high in vegetables, actually much higher than most Western diets, seeming to indicate a fruit specific effect.  I speculate that just as we see a salt sensitivity with regard to hypertension in those of African descent, maybe there's something about Asian ethnicity that makes the fruit factor important.  In any case, perhaps we're going to see more fresh fruits on the menu in Chinese restaurants. Other topics this week include atrial fibrillation after cardiac surgery and statins for intermediate risk people, also in NEJM, and in JAMA, recommendations from the USPSTF on screening for COPD.  Until next week, y'all live well.

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iStock_000056500374_MediumWhen people choose to leave the hospital near the end of life, do they die more quickly than those who elect to stay?  Rick and I discuss this study on PodMed this week, as published in Cancer, and were both informed and pleased to learn that those who go home live longer in the short term, over days and weeks, than those who remain hospitalized, while those with a life expectancy of a few months live about the same length of time.  Our hope is that this study will relieve the burden of guilt experienced by some family members and loved ones that someone isn't receiving the very best care and may die more quickly at home.

Just over 2000 patients were enrolled in this study, conducted at 58 palliative care practices in Japan. Here's the data: A total of 1607 patients actually died in a hospital, and 462 patients died at home. The survival of patients who died at home was significantly longer than the survival of patients who died in a hospital in the days’ prognosis group (estimated median survival time, 13 days [95% confidence interval (CI), 10.3-15.7 days] vs 9 days [95% CI, 8.0-10.0 days]; P5.006) and in the
weeks’ prognosis group (36 days [95% CI, 29.9-42.1 days] vs 29 days [95% CI, 26.5-31.5 days]; P5.007) as defined by Prognosis in Palliative Care Study predictor model A. No significant difference was identified in the months’ prognosis group. Since most people identify their preference as dying at home, this study should support both patients and their loved ones in making such a decision.

Other topics this week include cardiac interventions following cardiac assessment prior to surgery in JAMA Internal Medicine, and two from NEJM: HRT timing and Lyme disease and long term antibiotic use.  Until next week, y'all live well.

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