Atherosclerosis in Servicemen

December 28th, 2012|Medical News Commentary|By

We all know that atherosclerosis, that deposition of fatty and calcified material on the inside of blood vessels, isn't good for anyone.  Disconcertingly, we know that the process can start in very early childhood with fatty streaks on the inside of vessels like the aorta, the body's biggest artery.  Now, as Rick and I discuss on PodMed this week, perhaps we can rest a bit on our laurels.  That's because the third study of US servicemen who've died while serving in the military shows a dramatic decline in the incidence of atherosclerosis over the last several decades, as reported in the Journal of the American Medical Association.

The first study to look at atherosclerosis in servicemen was done in those who fought in the Korean war, and was reported in 1953. This study showed that 77% of servicemen killed in the war had atherosclerosis in their coronary arteries, those that supply the heart with blood.  A second study on servicemen in the Vietnam war found a prevalence of 45% in the same vessels.  This current study on servicemen who died of combat or unintentional injuries between October 2001 and August 2011 reports that only 8.5% had any atherosclerosis in their heart vasculature at all, with greater than 50% occlusion in one or more vessels, so-called severe disease, in 2.3%, moderate occlusion in 4.7%, and minimal in 1.5%.  The total number of subjects for whom an autopsy was performed was 3832, of whom 98.3% were male, with an age range of 18 to 59 years. As Rick points out in the podcast, while none of us wish death to our servicemen, these studies demonstrate a very impressive reduction in the incidence of atherosclerosis over several decades.  To what do we attribute this precipitous decline?

The authors speculate that two major categories of factors must be considered: a real decline in cigarette smoking, high blood pressure, unhealthy cholesterol levels, and diabetes among servicemen, and artifactual differences in the studies regarding what constitutes atherosclerosis.  Additionally, military recruits today may be considerably healthier than conscripts in the Korean and Vietnam wars, giving rise to a bias called the 'healthy warrior' effect. While the artifacts must be considered, the data seem to indicate that efforts to modify risk factors may be bearing fruit, thus reducing the number of people with coronary artery disease.

Caution, however, is warranted given the fact that heart disease remains in the number one spot when it comes to causes of death, both domestically and in other developed nations. Obesity and diabetes are on the rise and are well-known to increase the risk of heart disease. And extrapolating from rates of atherosclerosis in servicemen to the general population seems risky at best.  For now, Rick and I agree that we're glad to see this decline but aren't quite ready to say well done!

Other topics this week include the risks of transfusion in folks who've had a heart attack in Archives of Internal Medicine, recurrent atrial fibrillation after ablation to try to correct the problem in the same journal, and modifying calcium and other micronutrients in people who are undergoing dialysis doesn't reduce mortality risk in NEJM.  Until next week, y'all live well.

 

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Rudolph’s Red Nose

December 21st, 2012|Medical News Commentary|By

As we have reached the winter solstice and the celebration of Christmas, that time of year so full of mysteries to ponder, Rick and I would like to help solve at least one of them: Rudolph’s red nose.  As we reveal on PodMed this week, the British Medical Journal has stepped out on a limb and published a serious scientific study of the reindeer’s nose, giving us all one more reason to believe.  I’ll describe the study, and for the skeptics among you, there’s even a very convincing video!

Handheld vital video microscopy (yikes) was used to assess the microcirculation of a reindeer’s nose and compare it to that seen in humans.  The blood vessel density in the human nose mucosa is known to be high, but the authors state that until the advent of this technique a really comprehensive study was impossible.  Yet it turns out that this vasculature is perhaps the best indicator of the circulatory system’s responses to drugs and conditions in people in the intensive care unit, previous studies utilizing this technique have reported. Who knew? Thus the authors decided to employ it in five consecutive human volunteers who were all nonsmokers, and two adult reindeer.  The humans received cocaine as a local anesthetic while the reindeer were lightly sedated using an intramuscular injection during the study.

The microvascular architecture, including networks of capillaries and hairpin-like vessels seen in the human were similar in the reindeer. The study reports a 25% higher functional vascular density in the reindeer, however, and a very curious physiologic phenomenon for which they’ve provided a video: during diastole the microvasculature of the reindeer is almost completely lacking in red blood cells, while during systole a very high density is seen.  Clearly, elucidating the functional advantage of such a phenomenon will require further study.

Video of thermographic images of a reindeer on a treadmill further corroborate the observations of the authors: http://www.bmj.com/multimedia/video/2012/12/18/why-rudolph’s-nose-red

For now, it's enough to see for ourselves that Rudolph does indeed, have a red nose, and that probably helps keep his nose from freezing as he zips around those high altitudes on Christmas Eve, as well as providing both his brain and his exercising musculature a heat releasing mechanism.  Go Rudolph!

Other, more serious topics this week include another from the BMJ on the use of hypnotic medications in folks with insomnia, and two from Lancet: a complete lack of benefit when antibiotics are taken by folks with lower respiratory infections, and another showing that treating whiplash intensively isn't helpful.  Until next week, y'all live well.

 

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Technology Aids Weight Loss and Control

December 14th, 2012|Medical News Commentary|By

Can DVDs and programs delivered by portable electronic devices help people lose weight and keep it off?  Yes, indeed, two studies in this week's Archives of Internal Medicine conclude.  That's really great news for the two-thirds of Americans and increasing numbers of people worldwide who are overweight or obese, Rick and I agree on PodMed, and it also helps beleaguered primary care practices to integrate technology into interventions that can be applied outside office visits or other time-sinks.  What did these studies do?

One of the studies randomized sixty-nine overweight adults to either standard care, including biweekly sessions with a dietitian, physician or psychologist to cover weight loss goals, nutrition, physical activity and behavior change, as well as weigh-in, or the above plus a personal digital assistant programmed to record food intake, physical activity, and to update goals.  This second group also received biweekly phone calls from a coach who provided individualized guidance based on the uploaded data. 

The group who received the personal digital assistant plus the coaching in addition to standard care lost 3.1% more weight relative to the standard care group.  One thing Rick really likes about this study is it was conducted in a Veteran's Administration population who were all self-admittedly technology-naive.  Thus it establishes not just the upside of utilizing technology to augment other weight loss and maintenance efforts but to educate those who may not be technology geeks to use such devices.  Now, of course, these would largely be smart phones rather than PDAs.

The second study had three arms and utilized the Diabetes Prevention Program lifestyle interventions to assist weight loss efforts.  One arm was usual care, another used a coach-led approach to implementing the program, and participants in the third arm were given a DVD to use at home.  At month 15 of follow-up the coach-led group had achieved a mean 2.2 reduction in body mass index (BMI), the home-based DVD viewers 1.6, and the usual care 0.9.  A 7% weight loss goal was achieved by 37% of the folks in the coach-led group, just shy of 36% of those in the DVD group, and in 14.4% of those in the usual care group.  Once again, the take home message is clearly that utilizing a multipronged approach to the problem of weight loss and maintenance results in more people meeting goals that translate immediately into improved cardiovascular risk.

Clearly neither of these studies reported a majority of subjects achieving goals and remaining there, so we have a long way to go to discern all the modifiable factors relative to overweight and obesity and to tailor interventions that are scalable, portable, inexpensive, and readily adopted by those who attempt them.  But these studies offer hope that we're on the right track, and may allow us to utilize strategies other than bariatric surgery to get our obesity epidemic under control.

Other topics this week include outcomes related to chest compression only CPR in Circulation, the management of obstructive sleep apnea at higher altitudes in JAMA, and preventing adolescent smoking in Annals of Internal Medicine.  Until next week, y'all live well.

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Thirty Years of Mammography

November 23rd, 2012|Medical News Commentary|By

Why screen for breast cancer, or any other cancer for that matter? The objectives of any cancer screening program are to diagnose disease that is likely to cause death at a stage where early treatment confers some benefit. Hmmm.  At least two issues right here: how to determine the characteristics of disease that’s likely to cause death, and whether early treatment really does produce a survival benefit.  Weighty issues indeed, and the subject of hefty grants to study the same.  As Rick and I discuss this week on PodMed, at least one of these questions is addressed in a study in the New England Journal of Medicine, looking at thirty years of data on screening mammography.

Data from the National Health Interview Survey and SEER (Surveillance, Epidemiology and End Results) areas were crunched for this study.  The idea was that if mammography screening over these three decades was successful, the number of women presenting with late stage breast cancer at diagnosis should decline, with a corresponding increase in the diagnosis of early breast cancers.

The data clearly show an increased adoption of mammography screening among women 40 years of age and older in the 1980s and early 1990s.  Detection of early stage breast cancers increased over the study period from 112 cancers per 100,000 women to 234 per 100,000, so mammography was successful in the detection of early stage cancers.  However, over the same period the detection of late stage cancers only modestly declined, from 102 cases per 100,000 women to 94 per 100,000.  Yikes.  Not much change there, bringing both the authors of the paper and Rick and me to the conclusion that there’s an awful lot of overdiagnosis going on here.

Okay, you say, so what?  Isn’t finding an early breast cancer a good thing?  Well, now we have to examine the consequences of treatment, including mental anguish, biopsies, lumpectomies, genetic analyses, and no doubt for some women, bilateral mastectomy and use of drugs like tamoxifen.

The study did find that during this period of time, there was a reduction in the rate of death from breast cancer, from 71 to 51 deaths per 100,000 women.  Yet the bulk of these fell to a group of women who wouldn’t even be ordinarily screened using mammography: those younger than 40. This points to improvements in treatment as the primary factor in reducing deaths due to breast cancer.

What does this mean in terms of the utility of screening mammography?  As I quip in the podcast, I’ve never been a big fan of mammography anyway and would be happy to increase the interval between screenings.  Clearly it points to the need for a better screening tool as well as a better way to discern the dangerous cancers.  Just as is the case in prostate cancer management these days, many if not most men can safely watch and wait, with regular follow up, to see if their own disease crosses the threshold in becoming a cancer that needs treatment.  My own prediction is that like prostate cancer, as time goes on we will see more and more women dying with rather than of breast cancer.

Other topics this week include a study panning routine health check ups in BMJ, adolescents and how they try to build muscle in Pediatrics, and the best way to repair an aneurysm on the abdominal aorta, also in NEJM.  Until next week, y’all live well.

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Lyme Disease- Recurrence or Reinfection?

November 18th, 2012|Medical News Commentary|By

Lyme disease, an illness that can be quite serious if left untreated, affects people living in many parts of the United States. Since it was described in 1975 after being identified in Lyme, CT, the infection has grown in both real frequency and myth.  Tranmitted by the tick Ixodes scapularis, commonly known as the deer tick, the causative organism is Borrelia burgdorferi, a type of bacteria. Following attachment by the tick, 24 to 36 hours are required for B.burgdorferi to be transmitted to its host, and often a characteristic rash known as erythema migrans develops at the site of tick attachment.  Now there's good news, as Rick and I discuss this week on PodMed: turns out that contrary to much popular opinion and the word on the street, most if not all cases of recurrent Lyme disease in people who've already had it and been treated are new infections, not recrudenscence of an existing infection. That's as reported in the New England Journal of Medicine.  So why is that good news? First let's take a look at the study.

A total of 17 patients in whom there were 22 paired consecutive  episodes of erythema migrans were reported in this study. Specimens of skin and blood were obtained from each patient and the organism cultured and genotyped. Additional molecular tests were also performed on the specimens.  Interestingly, only 27% of the subjects recalled a tick bite at the site of erythema migrans development in the previous 30 days.

The same genotype was not identified in any of the paired infections, indicating clearly that each episode was caused by a different strain of the bug.  Additional factors such as the time of year during which infection occured and the length of time between infections were consistent with this conclusion. The take home message for people who receive a diagnosis of Lyme disease is that when they complete their antibiotic treatment, they can feel confident the infection has been eradicated and not worry about the constellation of negative sequelae that can develop when an infection isn't properly diagnosed and/or treated. YAY!

Lyme disease, of course, has a lot of panic attached to it among many, and that's because the symptoms of tertiary disease are dire indeed.  Thus rabid advocacy groups have stridently proclaimed that Lyme requires a complex and prolonged treatment course during which hypervigilance is required.  Maybe now that this study has been published some of the fever will die down.  It is true, as Rick points out in the podcast, that sometimes even when the treatment course has been completed and the organism eradicated, symptoms such as arthritis, that may be severe, remain.  The current explanation for this seems to be that Borrelia ramps up the immune response, which then takes some time to return to baseline.  Tough for those who are living with it to deal with but much less serious than disseminated Lyme.

Other topics this week include steroid injections for sciatica, fungal infections secondary to steroid injection, and probiotics for Clostridium difficile infection, all in Annals of Internal Medicine.  Until next week, y'all live well.

 

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Are You Really Hearing Me About Chemotherapy?

November 16th, 2012|Medical News Commentary|By

People with advanced colon or lung cancer who are offered chemotherapy by their physician often do not understand that such treatment isn't going to be nor is it intended to be curative, a recent study in the New England Journal of Medicine concluded.  As Rick and I discuss in PodMed, this illustrates an opportunity for everyone involved to look more closely at communication, expectations, and end of life plans in the interest of compassionate care. So what did the study do?

Patients with newly diagnosed metastatic lung or colorectal cancer from five different geographic regions in the United States were enrolled into the Cancer Care Outcomes and Research and Surveillance (CanCORS) study.  About 10,000 patients older than 20 years who received such a diagnosis between 2003 and 2005 participated.  All study participants had stage IV cancer at diagnosis and opted to receive chemotherapy.

Experience of care, outcomes, personal characterisitcs and decision making on the part of each subject were all assessed by a professional interviewer by telephone 4 to 7 months after their diagnosis.  If the subject was not available due to death or illness a surrogate was queried. Almost 94% of patients with stage IV lung or colorectal cancer who were alive at the time of the baseline survey chose to receive chemotherapy; 69% of patients with lung cancer and 81% of patients with colorectal cancer had inaccurate expectations about whether chemotherapy was likely to cure their cancer.

African Americans and Latinos were more likely to maintain misconceptions than white patients. Ironically, those patients who rated their physician's communication skills more poorly were less likely to harbor misconceptions about the potential role of chemotherapy in their treatment.  Interestingly, education, functional status and the patient's own role in decision making had no impact on patient perception about chemotherapy.

Why are we so concerned about inaccurate patient perceptions?  Must we emphasize the terminal nature of someone's disease and then continue to revisit the issue until we're convinced they get it?  The authors make the point that when someone has inaccurate perceptions about the goals of care, they cannot be said to be giving truly informed consent to their treatment.  Moreover, as Tom Smith, director of palliative care here at Hopkins points out, such misperceptions may preclude a person's volition and ability to make end of life plans consistent with their own wishes, and that can be tragic.

How can providers help?  The training program at Johns Hopkins teaches physicians to revisit the idea of prognosis and likely outcomes at each stage of disease with their patients, so awareness is greater and choices can be made. Tom Smith advocates for an open discussion about things like power of attorney for healthcare, advance directives and the like.  In his clinical experience he reports that far from being upset by such topics, people welcome the opportunity to carefully consider their options. 

Other topics this week include treatment of knee osteoarthritis, when and what modality is needed for colon cancer screening following an initial negative colonoscopy, and sulfonylureas for diabetes, all in Annals.  Until next week, y'all live well.

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Smoking and Death in Women

November 3rd, 2012|Medical News Commentary|By

Unless you've been living under some slimy rock, you're well aware that there is nothing even remotely beneficial about smoking, and anyone who's listened to PodMed has heard Rick and me pontificate about what an eloquent indictment of our society it is that such a product is actually allowed to be sold anywhere in the world.  After all, people die of smoke inhalation.  And in this week's Lancet, an elegant study shows just how many women have died as a result of this repulsive habit.

The first thing that must be noted about this study is its incredible size.  Over 1.3 million women in the UK were recruited to participate.  Wow.  Such a number could only have been possible in a European country, where centralization of healthcare is much more common, as is record keeping.  Recruitment took place from 1996 to 2001, with these women having been born between 1938 and 1946. They were followed to January 1, 2011. All women with pre-existing disease were excluded from the study.

Twenty percent of the women were smokers at the time of recruitment, 28% were former smokers, and 52% had never smoked. During the follow up 6% of the participants died at a mean age of 65 years. Here's the finding that should be trumpeted from the rooftops: women who smoked died about 11 years earlier than nonsmokers.  That's 11 years, folks, as our colleague at Johns Hopkins, Enid Neptune, a pulmonologist frames it, that's the difference between watching your grandchild reach his third birthday and his fourteenth birthday: quite a lot of life lost.  It's also important to emphasize that at the time of recruitment, none of these women felt ill or had symptoms of disease, so things went fast. The excess mortality among women smokers was largely accounted for by diseases like lung cancer that are clearly caused by smoking.

There is some good news from this study: women who stopped smoking reduced their risk of mortality substantially.  Those who stopped by age forty had only a 20% increased risk compared to never smokers, while those who stopped by age 30 retained only a 5% risk.  A very persuasive reason to stop, especially juxtaposed against the fact that mortality risk remained among smokers even when they reported smoking 10 or fewer cigarettes per day.

Rick points out that this is the first study to gather substantial long term data on women smokers, who didn't begin smoking in large numbers until the 1960s.  I recall an advertising campaign for the Virginia Slims brand of cigarettes using the slogan 'you've come a long way, baby.' How unfortunate that independence  also sorted with adoption of the male-associated  habit of smoking! And indeed, that's the concern now.  In developing countries, as women gain more status they are also smoking more, and when that habit is added to environments where the air quality is often poor, an epidemic of early death looms.

Other topics this week on PodMed include an outbreak of mumps in a select group of people in NEJM, use of topical ivermectin to treat head lice in the same issue, and consumption of omega-3 fatty acids and stroke prevention in BMJ.  Until next week, y'all live well.

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Diarrhea and Death

October 27th, 2012|Medical News Commentary|By

Chances are good that even if you're not a healthcare provider you've heard of noroviruses.  That's because these nasty little beasties have been responsible for many a party boat, a.k.a cruise ship, limping into port with hundreds of passengers aboard confined to their cabins with vomiting and diarrhea. Such stories make the news perhaps because they give us landlubbers a reason to feel smug.  In any case, noroviruses are again in the news, as Rick and I discuss on PodMed this week.  That's because they're associated with increased mortality among older people who live in long term care facilities, in this week's JAMA.  In fact, infection with a norovirus is an important cause of death, and according to one expert at Johns Hopkins, William Greenough, one that's largely avoidable.

On to the study.  Medicare-certified nursing homes in Oregon, Pennsylvania and Wisconsin that reported at least one norovirus outbreak to the National Outbreak Reporting System between January 2009 and December 2010 were included in the dataset. Deaths and hospitalizations during this period were tallied and correlated with the norovirus outbreak. Both hospitalizations and deaths were increased during outbreaks, especially in the initial week and the first two weeks. One very important observation was that those facilities with a lower RN to resident ratio experienced higher rates of both hospitalizations and deaths relative to norovirus infection, suggesting, as Rick points out, that family members could perhaps weigh this factor when it comes to selection of long term care facilities.

Rick and I both find it astonishing that until this study, we've never really talked about diarrheal illnesses and mortality on PodMed, yet CDC data are compelling: of the 800 or so norovirus-associated deaths annually, 90% occur in people 65 and older. While Clostridium difficile remains the more problematic bug, these are still numbers that deserve attention and are likely to increase as the numbers of older people grow larger.  So what can be done?  As I mentioned before, William Greenough, an expert in oral hydration therapy at Johns Hopkins, says quite a lot.

Oral hydration therapy is so very simple and has been proven effective in developing world countries such as Bangladesh, Greenough says.  Very simple formulations such as Pedialyte or a rice-based concoction Greenough has helped develop and has a proprietary interest in can stave off death in the majority of cases of norovirus infection.  Turns out that even when someone continues vomiting or has severe diarrhea, they still retain the vast majority of what they drink and don't develop dangerous dehydration, which then can lead to infarcts and death.  For the elderly population, this means having someone help push fluids since they may not feel dehydrated or want to drink anything.  Greenough reveals that even a homemade preparation of a rice-based instant breakfast cereal and a small pinch of salt will serve quite well, diluted to a drinkable consistency.

Other topics this week on PodMed include peripheral arterial disease in men and the treatment effects of large studies, also in JAMA, and rates of bystander-initiated CPR in different neighborhoods in NEJM.  Until next week, y'all live well.

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Sleep and Fat

October 19th, 2012|Medical News Commentary|By

Short sleep duration and a host of deleterious health conditions for people are linked, increasingly abundant evidence concludes again and again.  Now a mechanism to help explain how sleep deprivation is biologically linked to aberrant metabolism, and from there to obesity and type 2 diabetes,  has been shown in an Annals of Internal Medicine study.  Perhaps this evidence may influence Rick to mend his chronically sleep-deprived ways, as we conclude on PodMed, although I am pessimistic about that particular outcome, especially in light of the fact that he is neither obese or diabetic.  On a population basis though, this study may help us get our arms around one factor that may be fueling the obesity epidemic.

In describing this study, I freely admit that I am a bit of a study junkie, having volunteered around our fine institution for a number of clinical investigations, and this is one I would have assiduously avoided.  That's because these 7 volunteers, 6 men and 1 woman, with a mean age of 24 years and of normal weight, first had to have a biopsy of their subcutaneous abdominal fat, endure sleep deprivation for 4 nights, then have another biopsy.  Yikes! My tolerance for sleep interruption is poor to begin with, and I can only imagine how that would impact on my tolerance for subcutaneous fat biopsy.  In any case, thanks to these brave subjects.

Sensitivity to insulin was assessed in the fat cells, or adipocytes, collected via biopsy, using the ability of insulin to increase the  phosphorylation of Akt, a critical first step in the insulin signaling pathway, in the cells.  Samples from each participant were compared following normal sleep (8.5 hours in bed) for four days and interrupted sleep (4.5 hours in bed) for four days.  Phosphorylation required about three times more insulin in the sleep deprived state than in the normal sleep state. The authors state that a reduction in total body insulin sensitivity paralleled this physiologic change. Well.  Could this be the linchpin connecting sleep deprivation with that downward slope of obesity, the metabolic syndrome, type 2 diabetes and its host of health consequences?  And if so, what can we do about it?

As Rick so aptly points out in the podcast, societally, we're chronically sleep-deprived. In the service of connectedness, multitasking, increased levels of stress, employment conditions and a host of other factors, many if not most of us just don't get enough sleep.  There's also the vicious downward spiral of obesity begetting sleep apnea, which then begets more fat accumulation and exacerbated breathing problems while recumbent.  What's a person to do?  One of my favorite phrases in medicine, "sleep hygiene," needs to be considered.  As we recognize our need for sleep, we need to make sure getting enough is a priority, just like exercise or sound dietary choices.  The bedroom should be a refuge, with temperature and lighting designed to facilitate sleep.  If we're wakeful, we need to get up and go elsewhere rather than toss and turn, and we need to pay attention to what we eat and how much before sleep, avoiding activities that may be overstimulating such as exercise (!), work, computer games and the like. And here's another fav of mine:  naps during the workday.  Hmmmm.

Other topics this week include the reuse of implantable cardiac devices, also in Annals, multivitamins in cancer prevention and HIV therapy in JAMA, and a new coronavirus in NEJM.  Until next week, y'all live well.

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Chocolate and Nobel Prizes

October 12th, 2012|Medical News Commentary|By

How would you like to win a Nobel prize?  If that's your objective, maybe you should start consuming more chocolate, and try to enlist everyone you know to do so as well, since as Rick and I discuss on PodMed this week, there's a linear relationship between chocolate consumption on a population level and the number of Nobel prizes a country wins.  That's according to a study with a really great graph, seen here, in this week's New England Journal of Medicine.  (And you always thought those august types at the Massachusetts Medical Society lacked a sense of humor...).  Let's take a closer look.

The hypothesis of this study was that dietary consumption of flavonoids, which are found in abundance in citrus fruits, gingko, berries, some types of tea, and chocolate, especially the dark variety, is known to delay the onset of dementia, and reduce the incidence of stroke, cancer and heart disease, depending on which studies you find believable, so is there a relationship between chocolate consumption and measures of intellectual function as evidenced by receipt of a Nobel prize?

Data from Wikipedia was used to assess numbers of Nobel prizes per capita for 23 countries. Population figures were calculated in tens of millions per Nobel winner, since clearly there are many more people simply residing in a country than there are Nobel winners in that country. Data on chocolate consumption in these countries was gathered from three different organizations with a vested interest in same.   When these data sets were plotted against each other a linear positive relationship emerged, with those countries consuming more chocolate having more Nobel winners to their credit.  Interestingly, there was one outlier: Sweden.  With 32 Nobel laureates during the study period, the country outperformed their predicted 14 prizes based on chocolate consumption.  One wonders, of course, about selection bias?

Questions I have that aren't addressed in the study are the type of chocolate consumption necessary to achieve a greater number of Nobels.  Is milk, my own personal favorite, okay, or is dark chocolate the only option?  Do nuts or fruits in a chocolate product dilute its impact? Clearly, as Rick points out in the podcast, this is an observational study only, and generates a hypothesis that can be tested subsequently in that time-honored way: prospective, double-blind, placebo-controlled, and so on, and most likely begun in childhood and continued for many years.  Kind of like "Charlie and the Chocolate Factory," a lifetime supply of chocolate, perhaps underwritten by industry...

On a somewhat more serious note, the author of the study discloses his own daily chocolate consumption as revelation of a possible conflict of interest. On a much more serious note, other topics this week include hormone replacement therapy, as published in the British Medical Journal but also another study presented at the North American Menopause Society, fibulin and mesothelioma in NEJM, and a novel device to support lungs for transplant in the Lancet.  Until next week, y'all live well.

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