iStock_000062992601_MediumYou've no doubt heard by now of our latest mosquito-borne scourge: Zika virus.  Rick and I discuss what's known so far on PodMed this week, per a Centers for Disease Control and Prevention alert.  And even as we ponder nomenclature for emerging viruses we also wonder at where the critters are hiding before they come to our awareness, and wreak havoc on fetuses of women who have the ill fortune to become infected. What do we know so far?

Zika virus is transmitted by our friend the Aedes aegypti mosquito, which is also credited with transmission of dengue and chikungunya.  The bug bites day or night, and the best protections include staying indoors in the AC or screened-in places, long sleeves and pants, repellent use and so on.  For women who are pregnant the agency recommends against travel to any area where the infection is active, and notes that women can be infected at any stage of pregnancy.  Pregnant or not, about 80% of those who are infected are asymptomatic, and even those who with symptoms experience nonspecific ones.  Thus the CDC recommends that any pregnant woman who has traveled to these areas be screened for possible Zika virus infection, with ultrasonography for follow up in order to detect microcephaly or intracranial calcifications. No doubt we'll all learn more as the medical sleuths get underway.

Other topics this week include PT and Parkinson's disease in JAMA Neurology, afib in women in the BMJ, and a theme issue on oncology end of life issues in JAMA.  Until next week, y'all live well.

 

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Probiotic pills conceptCan probiotics help stave off the development of type 1 diabetes in infants at risk to develop the condition?  In a provocative study in this week's JAMA Pediatrics Rick and I talk about on PodMed  this week, the answer seems to be yes, at least in those with a specific mutation. Researchers gathered data from almost 7500 children at risk to develop type 1 diabetes from six clinical centers, three in the US and three in Europe.  Blood samples to assess antibody development to islet cells of the pancreas, one target of autoimmunity in the disease, were collected every 3 months when the children were between 3 and 48 months of age and then every six months thereafter. The cohort was stratified with regard to consumption of probiotics as this is common practice in Europe but not in the US. The data showed that those children who had one genotype, called DR3/4, and who consumed probiotics were at a greater than 60% reduced risk for developing diabetes compared to those not exposed but who had the same genotype. Pretty powerful stuff, in my mind, and well worth assessing in a prospective, randomized fashion. Now for finding an effective intervention for all those other at risk!

Other topics this week include a JAMA study showing that one-third of adult cancers may be due to inherited genes, JAMA Pediatrics on influencing food choices in middle and high school students, and the true value of cancer screening tests in the BMJ.  Until next week, y'all live well.

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iStock_000022047429_MediumChronic lymphocytic leukemia, abbreviated CLL in medical parlance, may have met its match with a new drug described in NEJM that Rick and I discuss on PodMed this week.  And since CLL affects mostly older individuals, a burgeoning population both domestically and globally, this is good news indeed.

The drug is called ibrutinib, and it is the first-in-class inhibitor of an enzyme known as Bruton's tyrosine kinase. The enzyme is known to be essential in survival and proliferation of immune cells gone awry in this type of blood cancer. Previous studies utilized ibrutinib along with other agents in people who had relapsed, or as primary therapy in patients having a specific genetic abnormality. This study used the drug in older, previously untreated patients. A total of 269 treatment naive subjects with CLL were randomized to either ibrutinib or chlorambucil. Improvements were seen in progression-free survival, overall survival, response rate, and hematologic variables.  Additionally, the oral agent was well-tolerated and associated with relatively mild side effects, including nausea, cough, diarrhea and fatigue, with 87% of patients in the ibrutinib group continuing to take the medication. Bill Nelson, director of the Kimmel Cancer Center at Johns Hopkins, calls this study practice-changing, and Rick points out in the podcast that among this group of people, who frequently have at least one other medical condition, the arrival of an effective agent with few side effects is terrific.

Other topics this week include CDC recommendations of opioid prescribing, a failure to counsel young women who are taking drugs associated with fetal malformations about contraception in Pediatrics, and use of electric fields in glioblastoma treatment in JAMA. Until next week, y'all live well.

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iStock_000061359348_MediumDoes being generally unhappy make you more likely to die?  Many people, ranging from new age types to medical professionals, have extolled the virtues of a positive outlook on improving health outcomes to actually  avoiding developing health problems in the first place. Indeed, our culture of happiness is so entrenched that some studies have reported cancer patients feeling guilty about their negative stance on life and its impact on their disease.  Now, as Rick and I discuss on PodMed this week and as published in the Lancet, comes a study that seems to dispel this relationship.

This investigation was part of the UK Million Women Study. Subjects were queried on feelings of stress, control. relaxation, health, and happiness.  One in six reported unhappiness, with smoking, lack of exercise, not living with a partner, and poor health associated with unhappiness.  Ten years later, after correcting for the lifestyle and health factors that were already present, the death rate for those who rated themselves unhappy was the same as that for those who identified as happy. Researchers explain this finding as a failure of previous studies to account for the impact on poor health on happiness.  As for Rick and me, we're adopting the mien 'don't worry, be happy' for 2016.  Other topics this week include too much measurement of hemoglobin A1c in those with type 2 diabetes in the BMJ, androgen deprivation and dementia risk in JCO, and a new drug for sickle cell disease in NEJM.  Until next week, y'all live well.

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78606771_thumbnailAre you familiar with PrEP, that strategy for treating people at risk for becoming HIV infected by using a combination medication marketed as Truvada? If you're like one-third of primary health care providers nationally, the answer is no, recent CDC data reveal.  And now, based on a study in NEJM Rick and I discuss on PodMed this week, it's even more critical that those at risk are offered the strategy.  That's because PrEP, which was proven successful in preventing acquisition of the virus in those at risk when taken on a daily basis, has now been shown to be effective when taken PRN.  Wow!  Not only does this make things more palatable for patients, it is also way less expensive.  This last is one of the primary barriers to use of PrEP among those offered the therapy.

The study results were as follows: "Of the 414 participants who underwent randomization, 400 who did not have HIV infection were enrolled (199 in the TDF-FTC group and 201 in the placebo group). All participants were followed for a median of 9.3 months (interquartile range, 4.9 to 20.6). A total of 16 HIV-1 infections occurred during follow-up, 2 in the TDF-FTC group (incidence, 0.91 per 100 person-years) and 14 in the placebo group (incidence, 6.60 per 100 person-years), a relative reduction in the TDF-FTC group of 86% (95% confidence interval, 40 to 98; P=0.002). Participants took a median of 15 pills of TDF-FTC or placebo per month (P=0.57). The rates of serious adverse events were similar in the two study groups. In the TDF-FTC group, as compared with the placebo group, there were higher rates of gastrointestinal adverse events (14% vs. 5%, P=0.002) and renal adverse events (18% vs. 10%, P=0.03)."

Well.  As Joseph Cofrancesco, an HIV expert at Johns Hopkins, has stated to me on multiple occasions, we have the power to stop this epidemic.  Now for the education, awareness, and political will to do so.  Other topics this week include two in JAMA: appropriate rate of C-section and how to manage obstructive sleep apnea, and in the BMJ, a critical look at methylphenidate in those with ADHD.  Until next week, y'all live well.

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iStock_000053775120_MediumIncreasing rates of Alzheimer disease (AD) threaten to overwhelm our health care system domestically and worldwide, but exactly what causes the condition remains controversial, as does diagnosis and monitoring.  Now a study in JAMA Neurology Rick and I discuss on PodMed this week adds more to our understanding of the pathology of AD in perhaps pointing the way toward monitoring more effectively.  Researchers recruited more than 500 'cognitively normal' people enrolled in the Mayo Clinic Study of Aging, median age 78 years.  Each of them had undergone a number of imaging studies, including MRI and two types of PET scanning as well as cognitive assessment. The data analyzed in this study were collected between January 2006 to January 2014.

A positive relationship between increasing amyloid levels and cognitive decline emerged, with those individuals having evidence of more amyloid accumulation more cognitively impaired.  In these same folks reduced hippocampal volume, slower metabolism of FDG-PET, and enlargement of the ventricles of the brain were also observed. These associations were independent of APOE4 carrier status.

The results clearly suggests means of monitoring those at risk for AD, although many of these studies are expensive and seem unlikely to provide a practical means of screening.  Rick points out that we still don't know whether amyloid causes AD or is simply a bystander, but we're both hopeful that studies underway attempting to reduce amyloid and examine impact on the development of AD will shed some light. Other topics this week include ACP recommendations on generic prescription in Annals of Internal Medicine, increasing colorectal cancer screening rates in Cancer, and folic acid supplementation and neural tube defects in the BMJ.  Until next week, y'all live well.

 

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iStock_000042347626_MediumCoffee lovers among us, and I count myself one of them, rejoice!  That's the substance of a study published in Circulation this week that Rick and I feature on PodMed, and the upshot is simple: coffee drinkers live longer.  Rick is of course quick to point out that this is merely an association and therefore does not prove causality, but as for me and my habits, this is one addiction I plan to continue.

What exactly did they do in this study? Researchers crunched numbers from the Nurses Health Study, the Health Professionals Follow-Up Study, and the second iteration of the Nurses Health Study, looking at consumption of coffee, including caffeinated and non-caffeinated varieties, as well as all cause and cause specific mortality.  They found that coffee consumption of from one to five cups per day was inversely related to mortality, whether that beverage contained caffeine or not.  Cause specific mortality also demonstrated an inverse relationship, including death from cardiovascular disease, neurological disease, or suicide. There was no association found between cancer risk and coffee consumption.

Other topics this week include measuring body temperature in Annals of Internal Medicine, and two from NEJM: an oral treatment for respiratory syncytial virus and germ  line mutations and cancer in kids.  Until next week, y'all live well.

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iStock_000017116914_MediumBelly fat is some pretty deadly stuff, Rick and I discuss on PodMed this week, based on a study in Annals of Internal Medicine.  Turns out that even if you have a normal body mass index or BMI, but you're carrying a doughnut around your waist, you're at significantly higher risk for death than either your normal weight counterparts without belly fat, or even those categorized as overweight or obese, but with a more distributed fat pattern.  And that's true for both men and women.

This analysis relied on data from the third NHANES study of more than 15,000 participants, and the findings are concerning.  As we speculate in the podcast, for someone with a normal weight it might be a bit of a tough sell to advocate for weight loss, especially given the well known fact that 'spot reduction' isn't a reality.  It's not really possible to simply lose fat from one's belly.  Rick says from a clinical standpoint, such a fat distribution pattern should be a clear signal to health care providers that interventions to make sure blood pressure and blood sugar are controlled and regular exercise undertaken are take-homes. We both agree that further research into the why of this body fat pattern as well as the mechanism by which it increases risk would be helpful.

Other topics this week include continuous versus intermittent CPR and intensive versus standard blood pressure control in NEJM, and the safety of silicone breast implants in Annals of Internal Medicine.  Until next week, y'all live well.

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iStock_000014270773_MediumCan you donate a kidney safely, with regard to your own long term kidney function?  As more people are encouraged to consider so-called 'live donation,' most often to provide a kidney to a loved one who needs one, it is incumbent upon physicians to inform this decision with as much accuracy as can be mustered.  Enter a study by Johns Hopkins investigator Morgan Grams and colleagues, published in NEJM this week, that Rick and I discuss on PodMed.

Researchers crunched data from a number of databases to look at overall risk of developing kidney disease during one's lifetime, then looked at the actual observed risk for kidney failure among living kidney donors.  They calculated that a constellation of risk factors, including age, race, presence of existing kidney function compromise, diabetes, obesity and others, can be employed to predict an individual's risk of developing kidney failure after donating a kidney.  The hope is that this calculator will enable clinicians to have frank discussions with their patients regarding risk.  The other possibility illustrated by this paper is that of older individuals being considered as donors.  As Rick so succinctly puts it in the podcast, chances are good if you haven't experienced kidney function compromise or failure by the time you're 65 you probably won't, and the calculator can help support that assertion. It's worth keeping in mind, of course, that no one's individual risk can be pinpointed with this or any method, since that outcome can only be known after donation has taken place.

Other topic this week include off label drug use in JAMA Internal Medicine, risk of malpractice claims relative to amount of testing a physician orders in BMJ, and in PNAS, an increased in mortality among middle aged Caucasians.  Until next week, y'all live well.

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HiResThe WHO has just declared processed meats a cause of cancer, with unprocessed red meat coming in as 'probable.' Rick and I agree on PodMed that while we are generally in support of this assertion, published in the Lancet Oncology, we are also in favor of moderation in almost all things and may snack on a processed meat item now and then.  And at least Rick maintains that his Texas roots preclude a complete ban on barbecue, so red meats will still provide an occasional repast.  On what does this august body base this recommendation, which I admit smacks somewhat PC to me?  Here's what happened:

"In October, 2015, 22 scientists from ten countries met at the International Agency for Research on Cancer (IARC) in Lyon, France, to evaluate the carcinogenicity of the consumption of red meat and processed meat. " In their examination of the body of evidence, which did not include any prospective, randomized studies, 800 epidemiological studies were included. The scientists discerned a dose-response relationship between consuming processed meats and development of cancer, specifically colorectal cancer.  While less robust, red meat consumption also conferred risk for colorectal, pancreas and prostate cancer.  Red,  by the way, includes mutton, lamb, goat and horse as well as the usual suspects beef and pork. What also seems clear from this analysis is that additional factors besides eating meat must also be operational.

Other topics this week include excess mortality associated with diabetes in NEJM, and two from JAMA: flavored tobacco product use among youth and almost 50 years of US mortality data. Until next week, y'all live well.

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