iStock-528438369What can people from the island of Sardinia teach us about the genetics of autoimmune disease and interaction with infectious disease resistance? Wow, that's a bit of a stretch out into serious nerd territory, but this study in NEJM that Rick and I discuss on PodMed this week is an intriguing demonstration of evolution at work, and potentially some other hypotheses. What did they do?

Researchers gathered data from almost 3000 persons with multiple sclerosis (MS), 411 with systemic lupus erythematosus (SLE), and almost 3400 controls from across Sardinia, as well as a population cohort of more than 6900 volunteers from elsewhere on the island. Case control data sets hailed from mainland Italy, the UK, Sweden, and the Iberian peninsula. Genome-wide association testing was undertaken and an area that encodes a cytokine and " drug target B-cell activating factor (BAFF)," was found to be associated with both MS and SLE.  The mechanism appears to be upregulated humoral immunity through increased BAFF levels, B lymphocytes and immunoglobulins. Most interestingly, this variant also seems to be beneficial with regard to malaria resistance, which has been historically endemic on the island. Evolution at work! We also speculate in the podcast on the role of autoimmune disease and lifespan, since Sardinia is home to the world's largest population of centenarians. At the very least it appears that there's no compromise of longevity, though testing those centenarians for the specific variant would be the best proof. For now, identifying and understanding more of the genetics and mechanisms of autoimmune disease works.

Other topics this week include Time to Colonoscopy After Fecal Testing and Colorectal Cancer and USPSTF recommendations on preeclampsia in JAMA, and in Stroke, Beverage Intake, Incident Stroke, and Dementia. Until next week, y'll live well.

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iStock-174295373Have you ever taken corticosteroids? I have, once, following a serious bout of poison ivy, and while at the time I really needed them I might think twice today. Turns out that single, short term use of steroids may cause a host of negative side effects, a new study Rick and I discuss on PodMed this week and published in the British Medical Journal shows. And since the study also shows that over 20% of adults in the US younger than 65 years of age have been given a prescription for oral corticosteroids, that's concerning indeed.

The study took a look at private insurance claims among adults 18-64 years old between 2012-2014. This represented claims by over 1.5 million adults, of whom over 327,000 received a prescription for short term (less than 30 days) use of oral corticosteroids. Most of these folks received their prescription from a multitude of providers for upper respiratory infections, spinal conditions and allergies. More likely to take the meds were older folks, women, and white adults.

When looking at possibly associated negative side effects, the study identified a disturbing and significant increase in sepsis, venous thromboembolism, and fracture among those who took steroids, even a single, short term use. Plausibility exists for these associations since these are the self-same warnings given by the FDA with regard to prescription of these drugs.  Yikes! What can be done? Clearly, monitoring the prescription of steroids more closely and assessing these associations prospectively is needed before panic ensues. Yet for now, carefully assessing prescription of steroids is also prudent.

Other topics this week include Azithromycin and ventricular arrhythmia in CMAJ, Screening for Retinopathy in Type 1 Diabetes in NEJM, and Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis in Annals of Internal Medicine. Until next week, y'all live well.

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iStock-505700149Low back pain is virtually a given for the majority of us, with studies showing that almost everyone will experience an episode, and some will have a recurring or longstanding problem. Now comes hope, as Rick and I discuss on PodMed this week and published in JAMA, in the form of a meta-analysis taking a look at spinal manipulation, or chiropractic, in improving pain.

Participants in these trials who were included in the analysis had acute, lower back pain of less than or equal to 6 weeks duration. Spinal manipulation therapy was able to reduce pain moderately and for up to six weeks, about the same as using a non-steroidal anti-inflammatory medication.  As Rick opines, that's pretty good as it avoids the harms associated with medications. What about the harms of spinal manipulation? The study found that such harms were transient and musculoskeletal in nature. On the detraction side is also the fact that chiropractic costs more than simply popping an OTC medicine. On the whole, however, the evidence tilts the scales in favor of attempting spinal manipulation, with Rick confiding that he has referred patients for this treatment with favorable results.

Other topics this week include The US Preventive Services Task Force 2017 Draft Recommendation Statement on Screening for Prostate CancerAn Invitation to Review and Comment, also in JAMA and which Rick encourages everyone to read and comment on, and from NEJM, Mortality and Cardiovascular Disease in Diabetes and Incidence Trends of Diabetes among Youths. Until next week, y'all live well.

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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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