Sildenafil, usually marketed under the brand name 'Viagra,' is a very popular drug in the US and around the world for treating erectile dysfunction in men. A recent analysis of the pharmaceutical industry revealed that sildenafil was in the top fifty drugs purchased in the last quarter of 2013.  Rather disturbing then, as Rick and I discuss on PodMed this week, that a JAMA Internal Medicine study reveals a possible association between the use of sildenafil and melanoma.  Yikes!  What's up with that?

The paper cites the fact that almost 80,000 new cases of melanoma will occur this year in the US alone, and that while the pathways underlying disease initiation and progression are complex, the RAS/RAF/MEK/ERK pathway is known to be important in most of them. Moreover, 50% of melanoma tumors have BRAF mutations, leading to elevated kinase activity.  The enzyme PDE5a is a downstream target of BRAF, downregulating it and allowing conditions that favor tumor growth. Lo and behold, sildenafil also targets the same enzyme! Thus the "smoking gun" or biological plausibility we all like to see when examining studies of this nature most definitely exists.

To investigate the association between sildenafil use and melanoma, data from the Health Professionals Follow-Up Study was utilized.  This study began with almost 52,000 US male health professionals enrolled in 1986. Over 90% of them have been faithful through biennial follow-up questionnaires over the interim. This study examined sildenafil use and both melanoma and non-melanoma skin cancers. Data regarding ability to achieve and maintain erection was gathered as well as skin characteristics such as number of moles, natural hair color, number of blistering sunburns, state of residence, and family history of melanoma.

The study identified 142 melanoma, 580 squamous cell , and 3030 basal cell cases during follow-up. Recent sildenafil use at baseline was significantly associated with an increased risk of subsequent melanoma with a multivariate-adjusted hazard ratio of 1.84, or almost twice the risk.  No such association was seen for either squamous or basal cell cancers. Erectile function itself was not associated with an altered risk of melanoma. Men who used sildenafil were likely to be older, weigh more, and have a history of severe or blistering sunburns.

As Rick is quick to point out, this study only provides an association, and therefore clearly needs follow up in the form of a prospective study, but we also agree that since many of the sildenafil prescriptions written nationally, and we suspect internationally, come from primary care physicians, a whole-body skin examination is also in order, with regular repeats while sildenafil is taken, and even after use ceases, as this study found an association with ever-use and melanoma risk as well.

Other topics this week include motion in people with paraplegia in Brain, zinc and colds in JAMA, and shock wave therapy for tendonitis in Annals of Internal Medicine.  Until next week, y'all live well.

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As any fan of Downton Abbey knows, preeclampsia can be a killer, as that was Sybil's way of exiting the show a couple of years ago.  Now, as Rick and I talk about on PodMed, a drug that was available then could have helped: aspirin.  That's according to a literature review and recommendations of the USPSTF published this week in Annals of Internal Medicine. What did they find?

First let's take a look at preeclampsia facts.  Worldwide, it claims 12% of the lives of women who die of pregnancy-related causes each year. Serious maternal medical illness is accounted for in one-third of cases by preeclampsia, and 15% of preterm births can also be attributed to the condition. Two to eight percent of pregnancies around the globe are affected, with risk factors including a family history of the condition in mother or sister, advanced maternal age, high BMI, and first pregnancy.

Preeclampsia is defined by a resting blood pressure of 140/90 mmHg or above, with protein spilling into the urine (proteinuria), observed at 20 weeks of gestation or later.  The blood pressure can be much higher, with impairment of cognition and vision, liver and kidney function, and pulmonary edema just some of the profound deleterious consequences. Intrauterine growth retardation also occurs.  The bad news is that once preeclampsia develops the only course of treatment is delivery, with its host of potential negative outcomes depending on development of the fetus. Yikes.  Where's the good news?

This analysis of 15 randomized, controlled trials of daily low-dose aspirin in high-risk pregnant women, along with 8 studies in average-risk women found a reduction in risk of developing preeclampsia of 2-5% and a reduction in intrauterine growth retardation of 1-5%, along with a 2-4% reduction in risk of preterm birth. Small impact, admittedly, but against the magnitude of the problem an outcome worth seeking, we agree.

Dosages of aspirin used in this study varied between 60mg to 150 mg and no short term complications relative to aspirin use were observed. The USPSTF does note however, that no long term studies of the impact of aspirin use during pregnancy on offspring were reported.  Other clear advantages to aspirin are its off-patent status, oral administration, and abundance of experience using it among medical professionals and consumers alike.  Clearly, to address the problem of preeclampsia worldwide a better candidate drug could hardly be dreamed of: cheap, shippable, chemically stable, low abuse potential...the list goes on.

Other topics this week include paternal obesity and autism spectrum disorders in Pediatrics, spironolactone and one form of congestive heart failure in NEJM, and oral therapy for hepatitis C, in the same journal.  Until next week, y'all live well.

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Blood pressure is rather a squirrelly thing.  We know that it increases with exertion, aging, for some with increased salt intake, and that chronic high blood pressure is associated with strokes, or cerebrovascular accidents, to use the vernacular, and can have pronounced ill effects on the heart and kidneys.  Thus the medical establishment has for many years striven to keep blood pressure under control, ideally about 120/80mm Hg, and that a multitude of medicines working by different mechanisms have been developed for this purpose.  But, as Rick and I discuss on PodMed this week, what about the 5-15% of people whose blood pressure is very high and who don't seem to respond to medical therapy?  Ah, ever resourceful, enter nerve ablation to the blood supply to the kidneys, the renal arteries. The darling of the intractable hypertension treatment world, this week's New England Journal of Medicine reports a trial in which this intervention falls from grace with a resounding thud. What happened?

Incredibly, this trial reports the first randomized, blinded prospective study to examine the utility of ablating the sympathetic nerves to the kidney using radiofrequency ablation in the control of hypertension.  For the non-medical types who may read this, the sympathetic nervous system provides us with our 'fight or flight' response, where we can go from a resting state to ready for anything in mere moments, largely because of two hormones, epinephrine and norepinephrine. A chronic state of chatter in this system has been linked to hypertension in the past. Previous unblinded trials seemed to show a huge benefit in treatment refractory high blood pressure or hypertension by ablating those nerves and the procedure is in use worldwide.  In this trial, in a 2:1 ratio, 535 patients with treatment resistant hypertension were assigned respectively to either radiofrequency ablation or a sham procedure.  That, as Rick opines, is the key, as the sham procedure bears every resemblance to the actual ablation, allowing for much more revelatory comparison.

The endpoints of the trial included office-measured blood pressure 6 months after the procedure or its likeness, and 24 hour ambulatory blood pressure, and the conclusion is simple: it didn't work.  The change in systolic blood pressure (the high number) for those who had the actual ablation was a reduction of about 14mm Hg while those who were sham-treated saw reductions of about 12 mm Hg.  Reductions were even more modest in the 24 hour ambulatory measurements.  Okay, then.  Time to turn toward other strategies for blood pressure management, and by the way, those numbers are being recalculated all the time as normal aging is considered as well as other factors. As I am so fond of advocating, avoidance of procedures is almost always a good thing, and here's another for the seemed like a good idea at the time heap.

Can a common erectile dysfunction medication help men who are having radiation therapy for prostate cancer avoid ED? That's another topics this week from JAMA, and in the same journal a look at transfusion risk.  Another for NEJM: what about bariatric surgery in people with diabetes after three years of follow-up?  Until next week, y'all live well.

 

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Cancer of the esophagus, the tube that conveys food from the mouth to the stomach, has increased by a whopping 600% over the last thirty years.  Yikes!  Rick and I expound on PodMed this week, that's a lot of cancer, and a cancer with a poor prognosis.  Now a study in this week's JAMA offers hope for people in the presumed early stages of the disease, using a technique called radiofrequency ablation.  Before citing the specifics of the study, I'd like to first describe why I used 'presumed' in the above sentence.  Research that is at least a decade old suggests that at least some of the rapid increase in the incidence of esophageal cancer is due to gastroesophageal reflux disease, abbreviated GERD, eroding the area of the esophagus that connects to the stomach over time.  That's because stomach contents are regurgitated back into the esophagus, where the tissue is susceptible to damage by the very acidic stomach slurry. Repeated injury leads to a stepwise progression through an inflammatory condition known as Barrett's or Barrett esophagus, until frank esophageal cancer develops.  This is thought to be the case for adenocarcinoma of the esophagus.  Yet attempting to reduce the acidity of reflux by H2 blockers or other types of antacids has proven disappointing in reducing progression, and at least one study I'm aware of also casts some doubt on the Barrett's esophagus goes to esophageal cancer link.  Indeed, today's study also reveals that many people resolve low grade dysplasia on their own, so the solid line relationship really can't be drawn.  Okay, but what about this study?

One hundred thirty-six patients with low-grade dysplasia were randomized to either radiofrequency ablation or to usual care with endoscopic surveillance.  Sixty-eight patients comprised each arm of the study with those who had ablation doing so by one of two techniques over a maximum of five treatment sessions. The primary outcome measure was progression from low-grade to high-grade dysplasia or adenocarcinoma of the esophagus over three years of follow-up. The trial was stopped early because of the clear superiority of the ablation in preventing progression, with almost 27% of the control group progressing compared with 1.5% of the ablation group.  Ablation reduced the risk of progression to adenocarcinoma by 7.4%.

Pretty impressive numbers, of course, and at face value appears to be clear evidence that radiofrequency ablation should be considered in folks with low grade dysplasia.  But hold on, Rick and I discuss.  People who entered this study were examined and their diagnosis confirmed by people who were expert in the field, and the authors themselves state that 50-85% of people thought to have low grade dysplasia were downstaged to Barrett's esophagus when an expert pathologist examined the biopsy.  Moreover there are some people who clear such conditions on their own, and it's worth considering helping that along with even more conservative measures such as weight loss, eliminating alcohol, chocolate, spicy foods and other irritants from the diet, avoiding eating within 4 hours or so of bedtime and so on.  In our quick fix culture this technique appears attractive but seems the potential for overuse is rife.

Other topics this week include screening and intervention for alcohol abuse in college students and measuring hemoglobin A1c as a risk factor for cardiovascular disease, also in JAMA, and e-cigarette use in JAMA Internal Medicine.  Until next week, y'all live well.

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Statins may now have yet another indication, Rick and I reveal on PodMed this week: help in halting brain atrophy in folks unfortunate enough to have progressed to secondary progressive multiple sclerosis, as reported in the Lancet.  And the number of people who do progress is quite large, since multiple sclerosis, or MS, afflicts literally millions of people worldwide.  While the exact prevalence is not known, what is known is that the condition usually develops when people are 20 to 50 years of age, with about twice as many more women than men affected.  After an initial presentation of what is called 'relapsing remitting' disease, where periods of acute inflammatory activity are followed by periods of relative stability, more than half of people with MS will eventually progress to the relentless form of the disease, with concomitant loss of function and a reduced life expectancy of 5 to 10 years.

The hallmark characteristics of MS are plaques, areas where myelin is destroyed in largely white matter areas of the brain and spinal cord, inflammation, and brain atrophy.  Enter statins, specifically simvastatin. In this study 140 subjects with secondary, progressive MS were randomized to high-dose simvastatin (80 mg) or placebo for 24 months. MRI scans of each subject's brain were obtained at baseline, 12 months and 25 months. Brain volume and number of lesions were assessed.  An additional outcome measure included clinical assessment of function and impact of the disease. Cholesterol was also measured.

Impressively, the study reported a 43% reduction in the annualized rate of brain atrophy among those folks who took simvastatin compared to placebo. Predictably, their cholesterol was also reduced.  The drug was well-tolerated and side effects were minimal.  While the brain atrophy score was positively impacted, no other measures demonstrated a benefit, including the appearance of lesions, or clinical or immunological assessments.  The authors conclude that the results are persuasive enough to more forward to a phase 3 trial, and we agree.  We also agree that based on the results of this study, it's likely that many physicians who treat folks with secondary progressive MS will begin prescribing simvastatin off-label, invoking what I like to call the 'chicken soup hypothesis,' that is, it can't hurt.  Said with a heavy New York inflection, naturally.

Clearly, another direction that occurs to us is the utilization of statins earlier in the course of the disease as a potential prophylactic measure.  Rick and I part company here as he cites the fact that effective immunomodulatory agents exist for the initial stages of MS, but I am intrigued by the evident anti-inflammatory effect of statins as discerned in a number of other conditions and situations and wonder if they might not be more helpful if used in this capacity. No doubt future studies will address this question.

Other topics this week include neuraminidase inhibitors and flu mortality in Lancet Respiratory Medicine, genetic profiles and impact of fatty food consumption in the BMJ, and H.influenzae risk in pregnancy in JAMA.  Until next week, y'all live well.

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We're always astonished, Rick and I opine on PodMed this week, when sacred cows are slaughtered in medicine, when some precept we've held dear is subjected to rigorous study and discredited.  Such is the case in this week's New England Journal of Medicine, where surgical checklists, those darlings of the patient safety world, had no impact on mortality or surgical complications.  Sacre bleu!  How can it be so?  Let's take a look at the evidence.

Our friends to the north, residents of Ontario, Canada, provided researchers with a 'natural experiment,' a plethora of data from acute care hospitals gathered before and after mandatory implementation of surgical safety checklists. The Ministry of Health and Long Term Care mandated use of surgical safety checklists beginning in July 2010, and hospitals could employ a list of their own devising, the WHO checklist (previously validated in a number of observational studies) or the Canadian Patient Safety Institute checklist. Each hospital is required to report compliance with surgical safety checklists to a publicly reported database, in which the hospital is individually identified.

Three month intervals were studied for all 133 surgical hospitals in Ontario, one concluding three months before checklist implementation, and one commencing three months after such a list was employed.  All surgical procedures performed during each period of study were included in the analysis. Outcome measures included operative mortality, defined as mortality occurring during hospitalization or within 30 days of the procedure, complications occurring within 30 days of surgery, length of hospital stay, rate of readmission within 30 days of discharge, and emergency department visits within 30 days of discharge.

Comorbidities, the patient's socioeconomic status, sex, age and several other factors were also considered. A total of 101 hospitals were deemed eligible for analysis, revealing an adjusted risk of death of 0.71% before checklist implementation to 0.65% afterward. Other outcome measures were similarly unaffected by utilization of a surgical safety checklist, with such a paucity of impact persisting with multiple means of analysis and utilization of different factors.  Well.  Seems a pretty supportable conclusion.  What are possible explanations?

Compliance could be an issue, the authors indicate, citing previous studies looking at actual rates of compliance and outcomes and showing a linear relationship between the two.  Training prior to implementation has also been shown to help, as does team training.  The authors also invoke the Hawthorne effect, where people who know their work is being scrutinized perform better than under normal conditions.  They also speculate that previous research demonstrating the very significant impact of checklists may have relied upon extensive checklists covering virtually the entire period prior to admission to discharge, or when checklists are implemented along with extensive training of care teams.  Finally, I would cite our colleague Peter Pronovost, a patient safety guru, who told me that once one source of potential errors is minimized or eliminated, it opens the door for other types of errors, an assertion borne out in research in many areas of safety.  For now, Rick and I agree, it seems very unlikely that such lists will be abandoned and perhaps this research will suggest a fruitful area for further endeavor.

Other topics this week include a new blood test for Alzheimer's disease in Nature Medicine, questions about whole genome sequencing in JAMA, and the problem of discontinued randomized clinical trials in the same journal.  Until next week, y'all live well.

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Since HIV became the worldwide scourge it is today, a very few people have somehow become infected, yet avoided disease progression and in some cases, cleared the infection.  Such an observation has also been made in at least one HIV-infected person who received a bone marrow transplant and has subsequently remained virus-free for four years.  As Rick and I discuss on PodMed this week, one common denominator among some of these folks is an aberrant receptor needed by HIV to gain entry to T cells, the class of lymphocytes preferentially infected by the virus.  As reported in the New England Journal of Medicine, this receptor, CCR5, has been genetically modified in the laboratory in T cells, the cells subsequently infused back into the person from whom they originated, and have been able to survive in spite of existing HIV infection.  WOW!

This study enrolled 12 patients who were HIV positive and taking antiretroviral therapy. Each of them received an infusion of autologous CD4 enriched T cells that had been modified with the use of a technology known as 'zinc finger nucleases,' or ZFNs. These amazing reagents can be used to generate specific double-strand cuts in DNA.  For this purpose they were used to bind to a site within the human chemokine receptor 5 gene (CCR5)  and modify it so that HIV was unable to dock to the receptor. Previous research had shown that lymphocytes modified in this way were still capable of responding to stimulation and otherwise functioned normally. Only one subject experienced an adverse reaction which researchers speculate was a transfusion reaction.

Over time these modified lymphocytes remained alive, HIV DNA decreased in most patients, and in one patient HIV RNA became undetectable.  Pretty cool, no?  The authors note that future steps need to include modification of both alleles for this receptor, after discovering that the patient whose HIV was rendered silent already possessed one copy of the CCR5 gene that was modified. They further speculate that autologous stem cells could be modified at both alleles and reinfused into patients, or any number of other strategies. What seems clear is that this study brings to fruition a long term goal of genetic modification that could expand well beyond HIV management.  Kudos!

Other topics this week include two provocative studies in JAMA on strategies to improve the life of children: the impact of casino opening on obesity in Native American children and the mental health impact in children of moving to more affluent neighborhoods from poverty stricken areas.  Our final study was another look at hepatitis C incidence in the United States in Annals of Internal Medicine.  Until next week, y'all live well.

 

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Pregnant women have a lot on their minds, I'm sure we'd all agree.  What with environmental exposures, mortality related to flu strains, psychoactive medications and even OTC meds, it's a wonder the process can be undertaken with any degree of composure.  Enter now, as Rick and I discuss on PodMed, a new type of test that is quick, noninvasive, and very reliable for indicating risk that a fetus might have a genetic abnormality known as aneuploidy, or too many copies of specific chromosomes, as published in this week's NEJM.  The test has the potential to reduce anxiety for pregnant women who undergo routine screening that more often than would be desirable indicates a potential problem.  Not only that, but for the nerds among us the technology is way cool and is rapidly making its way through many other areas of clinical medicine.  What's it about?

Turns out that a bit of fetal DNA is shed from the fetal contribution to the placenta into the maternal circulation.  In the common vernacular that's some of the baby's DNA makes it into mom's bloodstream. This is known in the parlance as cell-free DNA or cfDNA.  There it can be detected when blood is withdrawn by a technique known as 'massively parallel sequencing.'  Yikes.  That means the baby's DNA fragments are detected and copied and analyzed to determine if too many copies of chromosomes 18 or 21 are present. These conditions are known as 'Edwards syndrome' and 'Downs syndrome.'  This last is the most common aneuploidy compatible with life, affecting some 1 in 800 live births and becoming increasingly common with increased maternal age.  Edwards syndrome affects 1 in 6000 live births.

This study is an extension of previous work demonstrating that this technique could be used with great sensitivity and specificity in women at high risk for having a fetus with an aneuploidy, such as older age or a previous pregnancy where aneuploidy was detected. In this case a multitude of low risk women were enrolled, and here's what the results report:

The primary series included 1914 women (mean age, 29.6 years) with an eligible sample, a singleton fetus without aneuploidy, results from cfDNA testing, and a risk classification based on standard screening. For trisomies 21 and 18, the false positive rates with cfDNA testing were significantly lower than those with standard screening (0.3% vs. 3.6% for trisomy 21, P<0.001; and 0.2% vs. 0.6% for trisomy 18, P=0.03). The use of cfDNA testing detected all cases of aneuploidy (5 for trisomy 21, 2 for trisomy 18, and 1 for trisomy 13; negative predictive value, 100% [95% confidence interval, 99.8 to 100]). The positive predictive values for cfDNA testing versus standard screening were 45.5% versus 4.2% for trisomy 21 and 40.0% versus 8.3% for trisomy 18.  This is impressive, we must admit, and calls for adoption of this screening for all pregnant women who choose to be screened.

Other topics this week include an enterovirus vaccine developed in China and causes of fever in African children in NEJM, and another analysis of vitamin E and selenium supplements and prostate cancer in the Journal of the National Cancer Institute.  Until next week, y'all live well.

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If you're a parent of a child who is having or has had recurrent ear infections, and I can answer yes on both counts, you have no doubt heard of tubes that can be placed in your child's ears to prevent infections so those tedious bottles of suspiciously flavored antibiotic solutions can presumably be jettisoned.  As Rick and I reveal on PodMed this week, recurrent ear infections in children are a BIG problem, providing the number one condition requiring medical treatment in children under the age of five years in the United States.  So what happens when you go ahead with the devices, known as tympanostomy tubes as well as a number of other names, and your child still gets ear infections????  That's the subject of a study in the New England Journal of Medicine this week, and it provides us with some good news regarding management.

Two hundred thirty children ranging in age from 1 to 10 years, all of whom had tympanostomy tubes placed but still developed ear infections, known in the parlance as otorrhea, were enrolled in this trial.  One-third were assigned to observation only, one-third to oral amoxicillin–clavulanate suspension, and the final third to a topical solution of hydrocortisone–bacitracin–colistin eardrops.  Regimens included  hydrocortisone–bacitracin–colistin eardrops, administered as five drops, three times daily, in the discharging ear or ears for 7 days, oral amoxicillin–clavulanate suspension (30 mg of amoxicillin and 7.5 mg of clavulanate per kilogram of body weight per day, divided into three daily doses administered orally for 7 days), or observation for 2 weeks.

Parents were asked to keep a diary of medication adherence, complications or adverse events for two weeks, and any ear-related symptoms for six months.  The study physician visited the child at home (study conducted in the Netherlands)  at 2 weeks and 6 months, examined the child's ears and collected the parents' diaries and questionnaires.  The study results indicate the clear superiority of the topical treatment to both oral antibiotics and observation in providing the shortest duration of otorrhea (4 days versus 5 days versus 12 days, respectively).  At 2 weeks of follow-up, 5% of children treated with the topical solution, 44% of those who received the oral antibiotics, and 55% of those randomized to observation remained symptomatic. As Rick and I opine on PodMed, the topical treatment avoids systemic side effects of oral antibiotic treatment such as diarrhea, as well as reducing the potential for developing antibiotic-resistant organisms.  Clearly, topical treatment will also reduce parental stress resulting from dealing with a child with a symptomatic ear infection, so sounds like a win-win to us. Could such a strategy be expanded to include additional populations of children with ear infections?  That's outside the scope of this study but seems worth consideration.

Other topics this week include the use a common antidepressant to treat agitation in Alzheimer's disease in JAMA, ablation therapy for atrial fibrillation in the same journal, and how to treat arteriovenous malformations found incidentally.  Until next week, y'all live well.

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Alcoholism is a huge source of disability and death in our world, as everyone knows. Survey data seem to conclude that about 10% of males and about 3% of females engage in heavy alcohol use, with 10.5% of males and 5.1% of females meeting the criteria for alcohol dependance or abuse in the past year.  Now, as Rick and I discuss on PodMed this week, a complicated study in the Lancet combining economic data with population studies supports the idea that raising the base price of alcoholic beverages would favorably affect alcohol consumption in the group that is most negatively impacted by such consumption: low income people.  Let's examine the study.

The authors employed the Sheffield Alcohol Policy Model, version 2.6, a UK-based database utilizing income and socioeconomic subgroup analysis of alcohol purchase and consumption preferences. Price, type, and place of purchase/consumption were included, as was stratification based on moderate, hazardous and harmful consumers of alcoholic beverages. Moderates were defined as those who consumed less than or equal to 21 units of alcoholic drinks per week for men and 14 for women, hazardous consumed 21 to 50 for men and 14 to 35 for women, and harmful consumed more than 50 among the men and more than 35 among women. A unit of alcohol was calculated as 8 gm or 10 ml of pure ethanol, which of course is not how these beverages are sold, so calculations must be made accordingly. These latter three frequency groups were further categorized into three income groups.  The groups were concomitantly analyzed against rates of morbidity and mortality when a baseline price of 0.45 British pounds ($0.75 US) per unit was imposed on all alcohol sales.

Why was this study done at all, since previous analyses have already estimated that price constraints would disproportionately impact the heaviest drinkers?  What is unique about this study is its use of health data to compel the argument, in light of the fact that the lowest socioeconomic groups bear the biggest brunt of the deleterious consequences of alcohol consumption on both economic and health outcomes. So what did it calculate?

All groups in this analysis immediately reduced consumption when a price floor was established. Those who drank moderately were least impacted, with the greatest change seen in the harmful drinker group, in the lowest income bracket.  Yawn.  But here's the compelling data: persons in the lowest income group would accrue almost 82% of the total reduction in premature death and an increase of over 87% of the quality-adjusted life years of the entire analysis.  Wow!  That's a lot of life saved. As I opine to Rick in the podcast, this model seems to me to be a lot like the one for cigarettes, where increasing price points drive down use, especially among those least able to afford it.  While not usually a fan of the adage that the ends justify the means, in this case such a strategy seems quite supportable and legislators should take note and employ same.  Revenues collected could be diverted to treatment programs thus creating even more benefit to society at large.  A win-win.

Other topics this week include the impact of number of doses of the HPV vaccine received on genital warts in JAMA, a possible treatment for restless legs syndrome in NEJM, and the risk of end-stage renal disease in live kidney donors, also in JAMA.  Until next week, y'all live well.

 

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