iStock-648781192Surprise! Turns out ethnicity alone really does have an impact on cardiometabolic risk factors, a study Rick and I discuss on PodMed this week and published in Annals of Internal Medicine reveals. And in the short term, that means that as part of the prescription of personalized medicine, ethnicity needs to be considered in determining someone's risk for cardiovascular outcomes, perhaps even as the primary reason for screening for risk factors. What did the study show?

The authors examined data from a couple of longitudinal studies: " 2622 white, 803 Chinese American, 1893 African American, and 1496 Hispanic persons from MESA (Multi-Ethnic Study of Atherosclerosis) and 803 South Asian participants in the MASALA (Mediators of Atherosclerosis in South Asians Living in America) study." Basically, the relationship between high fasting glucose, low levels of HDL, high triglycerides and high blood pressure, so-called cardiometabolic risk factors, and body weight was examined. The authors coin a term "metabolic abnormality but normal weight (MAN)," to describe the results, revealing that for various ethnicities, even those of normal weight had 2 or more cardiometabolic risk factors.

Twenty-one percent of whites in this study met the MAN criteria, compared to 32% of Chinese Americans, 31% of African Americans, almost 39% of Hispanics, and almost 44% of South Asians. Wow! It would be possible to miss a screening opportunity in almost half of one's patients if only obesity or overweight was the criterion that tipped the scales in favor of a closer look, something that those in primary care might want to keep in mind.

Other topics this week include another from Annals:Weight History and All-Cause and Cause-Specific Mortality in Three Prospective Cohort Studies, one from Pediatrics: Influenza Vaccine Effectiveness Against Pediatric Deaths: 2010–2014, and one from JAMA: Trends in Thyroid Cancer Incidence and Mortality in the United States, 1974-2013. Until next week, y'all live well.

 

 

 

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iStock-124870447Imagine becoming a quadriplegic. Most people consider such possibilities with horror, and it's no wonder so many in this condition also become depressed.  Now enter hope, in a study Rick and I discuss on PodMed this week and published in the Lancet. The paper reports a single case study of an individual who, over the course of two years, regained quite a lot of function in one limb, and can now eat, drink coffee, and even scratch his own nose with impressive accuracy and reproducibility.  How did this happen?

The patient reported in this study had a bike accident, experiencing a high cervical (neck) spinal cord injury and subsequent tetraplegia, which this paper has educated me is another word for quadriplegia. At the time of recruitment to the study he was 53 years old. After rather extensive study, the team of researchers mapped areas of his brain involved in volitional movements of his right hand, and upper and lower arm, after which electrodes to stimulate those areas were implanted. Training with a computer and prosthetic arm, followed by subsequent implantation of electrodes and training of his paralyzed arm, have resulted in the outcome described. Easy for me to write in a few sentences but having taken two years to bring to fruition!  But what an outcome, and source of hope for others experiencing sudden accidents that leave them paralyzed. Kudos, we say, and look forward to further research to advance such efforts.

Other topics this week include Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs in Annals of Internal Medicine, Bioresorbable Vascular Scaffolds in Routine PCI in NEJM, and Impact of total knee replacement practice in the BMJ. Until next week, y'all live well.

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iStock-511380088How much of your chance to develop cancer is under your control? Not much, unless you have a family history of particular cancers or you are still smoking, sunbathing without sunscreen, or are obese, a startling study in the journal Science Rick and I discuss on PodMed this week reveals. Authors Bert Vogelstein and Cristian Tomasetti analyze data relative to mutations, known to be the cause of cancer, and how they are stimulated to occur, and find that the majority of mutations are random, accumulating over time until in some cases, they cause a cancer to develop.  How did they reach such a conclusion?

Tomasetti and Vogelstein studied the "relationship between the number of normal stem cell divisions and the risk of 17 cancer types in 69 countries throughout the world." Previous research had demonstrated that the greater the number of divisions cells of a tissue undertook the greater the risk of developing cancer.  This work demonstrates that for some tissues, for example, lung, environmental exposures, in particular smoking, produce about two-thirds of the cancers, but for the majority of all cancers, two-thirds or more are the result of random mutations.  That means that our ability to control cancer development by lifestyle choices is very limited, and of course to control cancers due to inherited genes, which account for about 5% of all cancers, is nonexistent.

What can we do then? Both authors opine that first, most people with cancer should jettison the guilt, (not those who continue to smoke, however!) since we can't control random. And we should focus our efforts as a research and medical care community on early detection, since the best chance to cure cancer lies in finding it before it becomes problematic. This is increasingly possible with the integration of imaging, genetic assessments, and screening. Finally, they propose that random mutations are the engine of evolution and are this necessary, so rueing the existence of this phenomenon is a lot like hating a pig for its grunt.

Other topics this week include Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active DiscopathyA Randomized Trial, in Annals of Internal Medicine, Direct-to-Consumer Advertising of Androgen Replacement Therapy in JAMA, and  Two Paradigms for Endovascular Thrombectomy After Intravenous Thrombolysis for Acute Ischemic Stroke in JAMA Neurology. Until next week, y'all live well.

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iStock-530196490People with cystic fibrosis (CF) who live in Canada survive longer with the condition than their counterparts in the United States, a study Rick and I discuss on PodMed this week and published in Annals of Internal Medicine finds. 10 years longer! That's a significant amount of time in anyone's estimation, and the reasons behind it are sobering, though Rick and I agree that they also provide an opportunity to improve.

Researchers crunched data from two registrations: the Canadian Cystic Fibrosis Registry (CCFR) and U.S. Cystic Fibrosis Foundation Patient Registry (CFFPR). The Canadian registry represents 42 CF clinics while the US registry represents 110 clinics. Almost 6000 Canadian patients were included in this study along with over 45,000 US patients with the disease, with results indicating that north of the border, people with CF live on average 51 years, while domestically age expectancy is 40.6 years.

Lung transplantation is more common for CF patients in Canada than in the US: 10.3% were transplanted and transplanted earlier than CF patients in the US, where only 6.5% received new lungs. I query in the podcast whether there is a difference in availability of lungs for transplant between the two countries but no data is reported on that in this study. Perhaps more sobering is the fact that when types of insurance patients in the US had were used to stratify CF patients, those without insurance or who had Medicaid were the ones who died earlier, while CF patients with good insurance lived as long as their Canadian counterparts. Therein lies at least one opportunity to even things up, as care continues to improve for this condition.

Other topics this week include Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee ArthroplastyThe HIHO Randomized Clinical Trial and Association of Preceding Antithrombotic Treatment With Acute Ischemic Stroke Severity and In-Hospital Outcomes Among Patients With Atrial Fibrillation in JAMA, and in NEJM, Rivaroxaban or Aspirin for Extended Treatment of Venous Thromboembolism. Until next week, y'all live well.

 

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iStock-498505467What can the 'oldest old' teach us about aging, and how has that experience changed over the last decade? That's the substance of a study published in the Lancet this week that Rick and I discuss on PodMed. The majority of the cohort, those in their 80's, don't seem that old to Rick, he quips because such an age grows closer daily, but some subjects were in their 90's or even 100+. The study compared almost 20,000 people aged 80-105 in China who were born 10 years apart and enrolled in the Chinese Longitudinal Healthy Longevity Study.  Data from 1998 and 2008 were included, and came to the conclusion that people are living longer but with poorer physical and cognitive functioning.  Hmmm. How was this assessed?

Data was gathered relative to physical ability (picking up a book, standing from a chair, turning 360 degrees), cognitive function, and self-reported activities of daily living.  For all age groups (80's, 90's, 100+) mortality decreased, but physical disability increased and cognitive ability decreased. The authors conclude that while we may be pushing back mortality frailty is increasing, and this must be acknowledged both in an individual's care but also in communities and at a policy level.  How applicable are these results to the world's aging population, as many of these subjects were low and middle-income? Rick notes that similar results were seen in a recent Swedish study also, so accounting for factors related to increasing frailty seems like the next step.

Other topics this week are all from JAMA: Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United StatesPeriodic Screening Pelvic ExaminationEvidence Report and Systematic Review for the US Preventive Services Task Force, and Effect of an Integrated Pest Management Intervention on Asthma Symptoms Among Mouse-Sensitized Children and Adolescents With AsthmaA Randomized Clinical Trial. Until next week, y'all live well.

 

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iStock-522188889Parkinson's disease (PD) is the second most common neurodegenerative disorder, with more than 1 million people affected in the US alone.  While many of us associate PD with characteristic trembling hands and a shuffling gait, the constellation of symptoms experienced by those with the disorder is much greater, and includes sleep disturbances, mood changes, depression, and excessive daytime sleepiness, among others. Now comes a study in JAMA Neurology Rick and I discuss on PodMed this week that uses timed light exposure therapy twice daily to ameliorate the sleep disturbance and daytime sleepiness.  And the great news is it worked!

The study was admittedly small, with only 31 patients whose medications were stable and who had excessive daytime sleepiness enrolled. Participants were randomized to receive either bright light or red light for one hour twice daily for two weeks. At the end of that time sleep fragmentation, daytime sleepiness, and time needed to fall asleep all improved in the bright light group.  And as Rick points out in the podcast, the therapy was easy to administer, could be done at home, and certainly bears further study for optimization.

Other studies this week include two from Annals of Internal Medicine: Maintenance of Weight Loss After Initiation of Nutrition TrainingA Randomized Trial and Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee PainA Randomized Trial, and in the BMJ, Low intensity pulsed ultrasound for bone healing: guideline. Until next week, y'all live well.

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iStock-537307838Great news for women who must have chemotherapy for breast cancer! The relatively simple measure of cooling the scalp before the administration of chemotherapy and then for a while afterward reduces hair loss quite a bit, Rick and I discuss on PodMed this week. That's as published in two studies in JAMA. And as Rick freely admits in the podcast, those of us who are fortunate enough not to have had treatment for cancer that includes prospective or actual hair loss may consider it a relatively minor inconvenience when compared with things like profound fatigue and vomiting, but a significant number of women cited in these studies identified hair loss as their reason for choosing not to undergo chemotherapy, potentially life-extending or not. So clearly developing ways to reduce or eliminate this side effect contributes substantially to quality of life.

The procedure to utilize the scalp cooling device was simple and in one study, involved cooling the scalp to 37 degrees F for 30 minutes prior to chemotherapy infusion, during the infusion itself and afterward for 90-120 minutes.  To me this sounds like extra time spent at the infusion center but more importantly if my head was chilled my body would follow! My hope is that heated blankets were provided to these women to avoid chills. Results for both studies indicated that hair loss was reduced by 50% or greater among those whose scalps were chilled compared to 0% reduction for those in the placebo arm.  Women who retained their hair also reported feeling more attractive than those who didn't. Rick cites a few thousand dollars added to the total cost of treatment by employing this strategy, and we both hope insurance will soon provide coverage for it.

Other topics this week include Associations of maternal BMI and insulin resistance with the maternal metabolome and newborn outcomes in Diabetologia, Opioid Prescribing and Risk of Long-Term Use in NEJM, and Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians, in Annals of Internal Medicine. Until next week, y'all live well.

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iStock-185126935People with sickle cell trait have one copy of a gene that can confer frank sickle cell disease to offspring, if combined with a second gene for the condition from a partner. As Rick and I discuss on PodMed this week, people with sickle cell trait may not have the often severe manifestations of sickle cell disease but they do experience consequences of the trait, specifically aberrant hemoglobin A1c measurements if they also have diabetes.  Since about 10% of African Americans do have sickle cell trait and the prevalence of diabetes is increasing, awareness of this is important for physicians and patients alike, as reported in JAMA this week.

Data from just over 4600 subjects from several different studies were examined retrospectively. The association of sickle cell trait with hemoglobin A1c measurements after controlling for fasting glucose or 2 hour glucose measurements was the primary outcome. Those with sickle cell trait had lower hemoglobin A1c levels for any given fasting or 2-hour glucose measurements, for an average of 5.72% versus 6.01% when compared to subjects without sickle cell trait. Clearly such a difference can skew interpretations of glucose control among those who also have diabetes, with Rick opining that this is yet one more factor doctors need to account for in using hemoglobin A1c.  We both acknowledge the fact that some investigators and clinicians are advocating for fasting glucose rather than hemoglobin A1c as a better metric for the state of an individual's diabetes, and suspect we'll be hearing more about this issue in upcoming studies.

Other topics this week include Prognostic Mutations in Myelodysplastic Syndrome after Stem-Cell Transplantation in NEJM, Nicotine, Carcinogen, and Toxicant Exposure: Comparison of E-Cigarette and Nicotine Replacement Therapy Users in Annals, and Pediatric Exposures to Veterinary Pharmaceuticals in Pediatrics. Until next week, y'all well.

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iStock-490025288Clinical trials might be considered rarified air, with all factors controlled for except for the one under investigation.  At least that's the hope. Now, as Rick and I discuss on PodMed this week and published in JAMA Internal Medicine, when data from a single clinical trial is used as the basis to inform lung cancer screening, results from the real world, or at least the Veteran's Administration manifestation of it, aren't so stellar, and in fact, call into question whether such screening should be done at all.

Just over 2100 current or former heavy smokers who were part of the VA population underwent low dose CT for lung cancer screening, as recommended by the United States Preventive Services Task Force (USPSTF), at eight sites in the United States. Almost 60% of this group had lung nodules; of that number just over 56% required tracking. Only 1.5% had lung cancer. A variety of incidental findings were identified as might be expected, but in short, there was a huge burden of counseling, screening and follow up for a very modest identification of people whose lung cancer was still potentially curable. Does this mean that we should simply abandon the practice of screening? As Rick opines, what's really needed, and seems to be poised on the horizon, is an accurate, easy screening test with not much in the way of false positives or false negatives. Hopefully such a blood test will become practical in the very near future.

Other topics this week include two from JAMA Cardiology: Association of Transcatheter Aortic Valve Replacement With Quality of Life and Cardiac Sympathetic Activity in Electronic Cigarette Users, and in the Lancet: Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Until next week, y'all live well.

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iStock-485935060C.dif is the abbreviation for one scourge of modern healthcare: an infection that often results in severe diarrhea, is challenging to treat, recurs readily, and may result in death. Now, as Rick and I discuss on PodMed this week and published in the New England Journal of Medicine, hope has arrived in the form of a new antibody to treat C. dif, or Clostridium difficile.

Turns out there are two antibodies against toxins produced by the organism reported in NEJM this week, but only the one against toxin B, known as bezlotoxumab, turned out to be much help. Over 2500 adults with primary or recurrent C.dif infection were included in this study, all of whom received standard oral antibiotics, followed by one or both antibodies or placebo. Those who received bezlotoxumab were more likely to achieve a sustained cure, that is no recurrence after initial clinical cure within 12 weeks, than those who received both antibodies or placebo.

The antibodies were administered by a single IV infusion following routine antibiotic therapy. The most common side effects reported by 2% of subjects included nausea and headache. Rick and I agree that these are impressive results and might be improved with more than one dose of the antibody or combination with fecal transplant.  Rick also advised me that the drug has just been approved by the FDA, so should soon be available widely.

Other topics this week include Association of Patient-Physician Language Concordance and Glycemic Control for Limited–English Proficiency Latinos With Type 2 Diabetes in JAMA Internal Medicine, a method for assessing medical devices once they're on the market Prospective Surveillance of Medical-Device Safety in NEJM, and Physician Decision Making and Clinical Outcomes With Laboratory Polysomnography or Limited-Channel Sleep Studies for Obstructive Sleep ApneaA Randomized Trial in Annals of Internal Medicine. Until next week, y'all live well.

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