iStock_44741540_MEDIUMIf you've ever had a kidney stone, or witnessed someone suffering the pain of "passing" one, the idea of simply taking a roller coaster ride to clear them out may be appealing.  In this novel study that Rick and I discuss on PodMed this week, as published in the Journal of the American Osteopathic Association, the efficacy of riding a roller coaster in dislodging renal calculi (that's medicalese for kidney stones) was examined, and lo and behold! riding in the back of the train was associated with an almost 70% success rate at displacing the stones into a position where they could be eliminated.

How did anyone ever get such an idea?  The authors had patients who reported passing kidney stones after roller coaster rides.  Based on these reports they decided to construct a kidney model, complete with real kidney stones suspended in urine from a patient.  Three different size calculi were used and placed in different anatomical locations in the kidney.  The model was placed in a backpack worn by one of the authors, and multiple roller coaster rides were undertaken.  Turns out the best coaster and position for dislodging stones was the rear car of the Big Thunder Mountain Railroad at Walt Disney World. The authors say that the best coasters for this purpose are those with a rough ride with multiple twists and turns, but not upside down loops or other inversions.  So for those of us who have renal calculi, maybe we should try this at home!

Other topics this week include two from Annals of Internal Medicine: Effect of Structured Physical Activity on Overall Burden and Transitions Between States of Major Mobility Disability in Older Persons: Secondary Analysis of a Randomized, Controlled Trial, and Effectiveness of Screening Colonoscopy to Prevent Colorectal Cancer Among Medicare Beneficiaries Aged 70 to 79 Years: A Prospective Observational Study, and one from JAMA Pediatrics:Health Status Among Adults Born With an Oral Cleft in Norway. Until next week, y'all live well.

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iStock_70133551_MEDIUMIf you're trying to lose weight, one great hope for assistance in that endeavor has been use of a fitness tracker. Such devices have been hypothesized to bring awareness to how much one is exercising or not, and to allow that data to be tracked over time and hopefully integrated with a comprehensive approach to weight loss.  So it is with chagrin that on PodMed this week, Rick and I discuss results of a JAMA study showing that fitness trackers not only didn't help people lose weight, the group using them did worse with regard to weight loss than the group who didn't use one! Yikes. What happened?

A total of 471 overweight and obese people 18 to 35 years of age were recruited to this long term study. A low calorie diet, increased physical activity, and group counseling sessions were all employed initially, with telephone counseling sessions, text messages and access to a website with study materials added at the six month interval.  At the six month point half the participants were supplied with a fitness tracker and web interface, while the standard intervention group utilized a website for self-monitoring.

The study continued for two years, with about three-quarters of participants completing the study.  Those who used the fitness tracker lost about 3.5 kg ( 7.7 pounds)  compared to the standard group, who lost 5.9 kg ( 13 pounds) on average.  Hmmmm.  Rick speculates that the robust support received by the standard intervention group has something to do with this outcome, but I'm really at a loss to explain it. Thoughts welcome.

Other topics this week include introduction of potentially allergenic foods into an infant's diet, also in JAMA, a look at beta blockers after heart attack in the BMJ, and in the Journal of Clinical Oncology an analysis of prostate cancer risk following vasectomy.  Until next week, y'all live well.

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iStock_60596186_MEDIUMThose of us of a certain age, and the young at heart likely remember Mary Poppins, who crooned, "just a spoonful of sugar makes the medicine go down..."  Now such a chant is likely to be met with boos from the medical establishment, as the august Circulation has weighed in on how much sugar a child should consume, and folks, as Rick and I discuss on PodMed this week, it's much less than a spoonful per day at least for the very young.

Keeping in mind that cardiovascular disease remains the number one cause of death worldwide, a writing group assessed all the available literature relative to the consumption of sugar in children and the development of said disease, or more properly, diseases that often result in cardiovascular outcomes. These were subsequently divided into five well-known conditions: diabetes and insulin resistance, obesity, high blood pressure, nonalcoholic fatty liver disease, and lipid aberrations. The inescapable fact emerged that such health problems developed at levels of sugar consumption far below what is currently recommended, specifically, depending on which guidelines are consulted, 6-10% of calories consumed per day.  Current NHANES data reports about 16% of calories for children consumed each day are from sugars.

What about changing such entrenched behaviors?  The study recommends that since no one really knows how much sugar is deleterious to the health of a child, things are simple:  no added sugar at all for children 0-2 years of age.  Children and adolescents may be able to consume approximately 6 teaspoons of sugar per day, but beverages should be limited to one eight ounce portion or less per week.  The committee opines that it wouldn't be bad for adults to get on board with these reductions either, since our worldwide problem with obesity continues unabated.

Other topics this week include a look at breast density and mammography frequency in Annals of Internal Medicine, and two from NEJM: a potential new treatment for essential tremor and the predictive value of genetic testing with regard to adjuvant chemotherapy in women with early breast cancer.  Until next week, y'all live well.

 

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iStock_27891038_MEDIUMHutterites have been figuring large in the medical research lately, with PodMed two weeks ago featuring a study on asthma and allergy in children in this community, while this week on the podcast Rick and I talk about a study comparing intramuscular flu vaccine to intranasal vaccine in two groups of these folks, as published in Annals of Internal Medicine. So we extend our thanks to the Hutterite people for agreeing to be a part of studies that advance knowledge for us all, in this case relative to flu vaccination methods.

The study was conducted over three influenza seasons among 52 Hutterite colonies in Alberta and Saskatchewan, Canada. Almost 1200 children ranging in age from 36 months to 15 years received a vaccine, while just over 3400 community members did not.  The study was designed to assess whether the live intranasal vaccine was superior to the inactivated intramuscular vaccine in providing protection for both the community (herd immunity) as well as the children.

Children were randomized to either the live attenuated intranasal flu vaccine against three strains of influenza, or to an inactivated vaccine containing the same three strains. About three quarters of the children in each group received the vaccine. There was no difference in the rate of influenza infection among either those vaccinated or persons in their community, with the authors concluding that there was no advantage to the intranasal live attenuated vaccine with regard to community protection.

I point out to Rick in the podcast however, that it also appears that the vaccine, marketed as FluMist, did work as well as the intramuscular vaccine, and may call into question the CDC's action of late June panning the intranasal vaccine for the upcoming flu season.  While I really did not like the one administration of this vaccine I received I am sympathetic to children who really don't like injections at all.  Time will tell, I suppose, on whether intranasal vaccines will return to favor.

Other topics this week include scrutiny of beta blocker use in those who've had stents in the Journal of the American College of Cardiology, a new osteoporosis drug in JAMA, and an association between Tylenol use during pregnancy and behavior problems in offspring.  Until next week, y'all live well.

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iStock_17258462_MEDIUMCan receiving text messages help improve a person's choices relative to reducing diabetes risk behaviors?  That was the central question addressed by a study Rick and I discuss on PodMed this week, as published in a journal we've never talked about before: the Journal of Medical Internet Research.  We're betting we will be hearing more from this journal as all over the world, the potential for using internet and mobile technologies to monitor, support and change choices that affect an individual's health is being undertaken, especially if the results equal or surpass those seen here.

This study was conducted in India among a cohort culled from a million Nokia phone subscribers. The study subjects received 56 text messages over the course of six months in their choice of 12 languages. The messages targeted fruit, vegetable and fat consumption and endorsed more exercise. A control group received no messages.  At the end of the study message receivers were more likely to consume more fruits and vegetables and attempt to reduce fat intake, although there was no improvement in exercise. The authors conclude that in low and middle-income countries, where diabetes risk is quite high and so is mobile phone access, such a strategy could have a great impact on new cases of diabetes in the future.  Questions we'd like to see answered would include the impact over a longer period of follow-up and the durability of results, but for now, we're encouraged.

Other topics this week include the impact of exercise on five common health conditions in the BMJ, ICU stays versus those on a medical floor with regard to outcomes in JAMA Internal Medicine, and insurance status and outcomes for two cancers in Cancer.  Until next week, y'all live well.

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iStock_6759635_MEDIUMWhat can Amish and Hutterite people teach us about genes, the environment, and the development of asthma?  Lots, according to a study Rick and I discuss on PodMed this week and published in the New England Journal of Medicine. This study looked at two groups of people who originally emigrated to the US from geographically similar central European areas and share the majority of their genes. They ultimately settled in two different farming communities in Indiana and South Dakota, respectively, and their farming practices are also distinct.  The Amish have generally small, family run operations while the Hutterites tend to work large corporate farms, thus their exposures are quite different.

It turns out the prevalence of asthma among the Amish children is just over 5% while  over 21% of the Hutterite children develop the condition.  Allergic sensitization is also divergent: 7.2% in the Amish versus 33.3% in the Hutterites.  By employing a mouse model, this study was able to demonstrate that dust from Amish homes inhibited airway reactivity and cellular proliferation characteristic of allergy. Researchers conclude that early and presumably sustained exposure to this allergen mix engages the innate immune response that is ultimately protective against asthma and allergy. Rick and I agree that precise identification of the allergens as well as timing of exposure may provide a likely therapeutic strategy to prevent asthma.

Other topics this week include a look at obesity, diabetes and cardiovascular events among a group of identical twins with divergent weights in JAMA Internal Medicine, off site cardiac monitoring in at risk patients in JAMA, and in MMWR, a look at preparedness nationally for preventing Zika-related fetal abnormalities.  Until next week, y'all live well.

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iStock_70075667_MEDIUMDid you know that the health impact of sitting at a desk job for eight hours a day is as deleterious as smoking cigarettes or being obese?  That's according to a Lancet study Rick and I discuss on PodMed this week, but there is good news:  you can offset your desk jockey occupation by exercising moderately 60-90 minutes five days per week.  Enough said!  Get out there and exercise.  But first let's take a look at the data.

This study was a meta-analysis including over 1 million people for whom sitting time and mortality statistics were available.  People were divided into four groups based on their physical activity and sitting time, with the reference group sitting less than 4 hours per day and reporting the most activity.  Compared with this group, those who were the least physically active experienced mortality rates 12-59% higher than those in the reference group. By contrast, those who were physically active but also sat for prolonged periods had no increase in mortality rates.  The authors conclude that physical activity was protective against the effect of prolonged sitting.

Rick and I both speculate on the ramifications of this study, wondering if it helps further inform an appropriate daily dose of exercise, something many professional societies have been circling around for years. Clearly this study suggests it's more exercise than has often been cited.  We also wonder if prolonged exercise one day a week, such as Rick's cycling behavior, counts against the daily totals or if more or less daily exercise is needed.  No doubt more research coming, but for now, we agree, almost everyone needs to move more and sit less.

Other topics this week include two others from the Lancet on depression and behavioral activation therapy, and the global economic burden of inactivity, and in JAMA, the USPSTF's recommendations on skin cancer screening.  Until next week, y'all live well.

 

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iStock_26372146_MEDIUMIf you're a woman who's had breast cancer, you may be taking a class of drugs known as 'aromatase inhibitors' to help reduce your risk of a a recurrence. Most women are recommended to take these medications for five years either following drug therapy with tamoxifen, or as initial therapy.  In either case, is there a benefit to continuing aromatase inhibitors for another five years?  That's the substance of a study Rick and I discuss on PodMed this week, as published in the New England Journal of Medicine. And the good news is, yes, there is additional benefit.  What exactly did the study do?

Over 1900 postmenopausal women with early stage, hormone receptor positive breast cancer were enrolled in this trial. Median follow-up was 6.3 years. Women usually entered the study after having received tamoxifen following their diagnosis of early breast cancer for five years, followed by an aromatase inhibitor for around five years.  They were then randomized to an additional five years on an aromatase inhibitor or to placebo.  Results indicated that 95% of women on the aromatase inhibitor were disease free at five years compared with 91% of those on placebo. More women developed breast cancer in the other breast in the placebo group than in the group taking the aromatase inhibitor. While those on the active drug did experience more bone pain, new onset osteoporosis, and bone fractures, Rick and I agree that the reduction in risk for breast cancer recurrence seems worth it, and that's good news.

Other studies this week include an analysis of the Mediterranean diet in Annals of Internal Medicine, risk of breast cancer following IVF in JAMA, and in Neurology, a look at whether HRT improves cognition.  Until next week, y'all live well.

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iStock_21783395_MEDIUMIf you have knee osteoarthritis, you've probably noticed for sale in pharmacies and elsewhere some rather ugly footwear purported to alleviate pain, and perhaps you've considered such a purchase.  Now, as Rick and I discuss on PodMed this week, there's finally evidence, as published in Annals of Internal Medicine, that you can give such a strategy a miss.  Here's what the investigators did:

A total of 164 people with knee osteoarthritis were randomized to wear shoes designed to unload their medial knee, the area where most people experience degeneration and pain, or to conventional walking shoes. They were instructed to wear the shoes daily and then were followed for six months.  At the end of the intervention period they were queried with regard to pain with walking and physical function. A number of secondary outcomes included knee stiffness, intermittent and/or constant knee pain, and quality of life. One hundred sixty subjects completed the trial.  And, as Rick and I quip in the podcast, it's time to boot those ugly shoes to the curb, as there was no significant difference between the groups on any measurement.  Rick and I agree that this study is especially helpful because there are a lot of devices being sold to help people manage common conditions like osteoarthritis that have never been scrutinized carefully, and we're hoping this is just the first study to do so.

Other topics this week include two from JAMA on HIV management, and one from the Lancet on mortality and obesity.  Until next week, y'all live well.

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iStock_84620773_MEDIUMShould physicians assist people who wish to end their lives? Whatever your view on that matter, a study Rick and I discuss on PodMed this week attempts to quantify just how much euthanasia, where the physician administers drugs to end life, or the patient does so with drugs a physician has prescribed, so-called physician assisted suicide (PAS), takes place currently in places where the practice is legal.  That's published in JAMA.

This rather exhaustive study took a look at the five countries where euthanasia and PAS is legal: Canada, the Netherlands, Belgium, Luxembourg, Colombia, and the five US states where PAS but not euthanasia are legal: Oregon, Montana, California, Vermont, and Washington. Survey data beginning in 1947 was examined through 2015, as was data from death certificates and locations with reporting requirements relative to these practices.  Briefly, the study found that while the practice is being legalized more and more, rates of actual utilization remain about the same.  There is no evidence that vulnerable populations are being targeted, and the group that seems to utilize the practice most often are people with cancer.

Of surprise to both Rick and me, pain was not the primary reason cited by people who chose to end their lives, but rather a wish to die with dignity, having experienced a loss of autonomy and ability to enjoy life. The majority of people who make this election are educated, white, and older. In short, we feel the study does not support the idea that somehow legalizing the practice would expand its use, perhaps to those who haven't chosen to die themselves.

Other topics this week include two studies we treated as one on breast cancer trials in NEJM, staph infections in families in Annals of Internal Medicine, and an IOM report on biomarkers.  Until next week, y'all live well.

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