iStock_000020076031_MediumIt's' a sure bet that any woman with a diagnosis of breast cancer would like to know whether chemotherapy is likely to benefit her before beginning such a regimen. As Rick and I discuss on PodMed this week, and as published in Cancer, that's the aim of the 21-gene recurrence score assay currently employed clinically.  The study specifically examines both how the test was able to inform treatment recommendations on the part of physicians as well as patient experience.The good news is that in employing the test in women in whom it is indicated, the gene assay seems to bring to fruition the promise of precision medicine. As well, it appears to be both racially and ethnically blind, as no difference across these groups were seen.

The study surveyed almost 4000 women treated for breast cancer in 2013-2014, identified from the Los Angeles County and Georgia Surveillance, Epidemiology, and End Results registries. Surveys, recurrence score and tumor data were linked, and showed that the majority of women who received a low recurrence score received a recommendation against chemotherapy, while almost all with a high recurrence score received a recommendation for chemotherapy. Women themselves reported being satisfied both with use of the test as well as treatment decisions. Of particular note, the authors write,"Personalized recommendations appear to reduce potential overtreatment with chemotherapy and nearly eliminated socioeconomic disparities in treatment after we controlled for clinical factors. This is a notable benefit of incorporating the RS into breast cancer treatment algorithms."

Other topics this week include Recurrence and Complications After Elective Incisional Hernia Repair in JAMA, and two from NEJM: Pulmonary Embolism in Patients Hospitalized for Syncope and Romosozumab in Postmenopausal Women with Osteoporosis.  Until next week, y'all live well.

 

 

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iStock_000053775120_MediumAs a hospital increases its number of ICU beds, more and more people are put on mechanical ventilation, even those with advanced dementia. That's the sobering conclusion of a study published in JAMA Internal Medicine that Rick and I discuss on PodMed this week, and one that also demonstrates no improvement in outcomes for these folks.

The study examined data from just over 380,000 Medicare beneficiaries with advanced dementia from 2000 to 2013. This group experienced over 630,000 hospitalizations.  During this time period use of mechanical ventilation among those patients with advanced dementia, about 75% of whom were bedridden prior to admission to the hospital, increased from 39 per 1000 hospitalizations to 78 per 1000 hospitalizations.  The likelihood that such a patient would be placed on mechanical ventilation increased as a hospital acquired more ICU beds, yet no improvement in outcomes was seen.

Yikes. Rick and I both agree that use of mechanical ventilation in many of these folks is questionable at best.  There are several likely scenarios where such a choice might be made but they point to a common problem: lack of accurate, timely communication between the patient, their family and loved ones, and the medical team.  This problem can be successfully overcome with use of a POLST, or in the state of Maryland a MOSLT: physician order for life sustaining treatment, or Maryland order for life sustaining treatment, respectively. This is an actual medical document that is created between the physician and the patient, or if the patient is unable to communicate on their own their healthcare proxy. It specifically delineates care preferences and along with advance directives, improves the odds that such ultimately futile care will not be rendered.

Other topics this week include Trends in Dietary Supplement Use Among US Adults From 1999-2012, an app for detecting atrial fibrillation: http://heart.bmj.com/content/early/2016/08/26/heartjnl-2016-309993.short?g=w_heart_ahead_tab, and calcium intake and coronary artery calcification: http://jaha.ahajournals.org/content/5/10/e003815.full.  Until next week, y'all live well.

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iStock_000062992601_MediumZika virus infection has circumnavigated the globe, with ongoing research efforts identifying more deleterious effects of infection.  This week, as Rick and I discuss on PodMed and as published in the New England Journal of Medicine, evidence has more definitively linked Zika in adults with the neurological syndrome Guillain Barre.  As we discuss in the podcast, since Guillain Barre may result in an ICU stays and the need for ventilation, and may also have long term sequelae, recognition of this association is important.

Investigators identified 68 patients with Guillain Barre syndrome in Colombia, South America.  A total of 66 (97%) had symptoms consistent with Zika infection prior to development of Guillain Barre, and virological studies were completed on 44 of those.  A median of 7 days elapsed between the onset of Zika virus infection symptoms and development of the neurological syndrome.  The researchers take the evidence of Zika virus infection in toto, including positive biological samples as well as antibody levels, along with the temporal relationship between development of Guillain Barre symptoms and Zika infection, and no evidence of Dengue infection or chikungunya, as consistent with a causative role for Zika.

Rick points out that such information is important clinically, since immune globulin may be helpful, and we both agree that this is a story that continues to unfold.  Other topics this week include Hospital Performance and Life Expectancy after MI,  Association Between Therapeutic Hypothermia and Survival After In-Hospital Cardiac Arrest. JAMA. 2016;316(13):1375-1382. doi:10.1001/jama.2016.14380, and Stimulant Medications and Bone Mass in Children and Adolescents With ADHD.  Until next week, y'all live well.

 

 

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iStock_44741540_MEDIUMIf you've ever had a kidney stone, or witnessed someone suffering the pain of "passing" one, the idea of simply taking a roller coaster ride to clear them out may be appealing.  In this novel study that Rick and I discuss on PodMed this week, as published in the Journal of the American Osteopathic Association, the efficacy of riding a roller coaster in dislodging renal calculi (that's medicalese for kidney stones) was examined, and lo and behold! riding in the back of the train was associated with an almost 70% success rate at displacing the stones into a position where they could be eliminated.

How did anyone ever get such an idea?  The authors had patients who reported passing kidney stones after roller coaster rides.  Based on these reports they decided to construct a kidney model, complete with real kidney stones suspended in urine from a patient.  Three different size calculi were used and placed in different anatomical locations in the kidney.  The model was placed in a backpack worn by one of the authors, and multiple roller coaster rides were undertaken.  Turns out the best coaster and position for dislodging stones was the rear car of the Big Thunder Mountain Railroad at Walt Disney World. The authors say that the best coasters for this purpose are those with a rough ride with multiple twists and turns, but not upside down loops or other inversions.  So for those of us who have renal calculi, maybe we should try this at home!

Other topics this week include two from Annals of Internal Medicine: Effect of Structured Physical Activity on Overall Burden and Transitions Between States of Major Mobility Disability in Older Persons: Secondary Analysis of a Randomized, Controlled Trial, and Effectiveness of Screening Colonoscopy to Prevent Colorectal Cancer Among Medicare Beneficiaries Aged 70 to 79 Years: A Prospective Observational Study, and one from JAMA Pediatrics:Health Status Among Adults Born With an Oral Cleft in Norway. Until next week, y'all live well.

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iStock_70133551_MEDIUMIf you're trying to lose weight, one great hope for assistance in that endeavor has been use of a fitness tracker. Such devices have been hypothesized to bring awareness to how much one is exercising or not, and to allow that data to be tracked over time and hopefully integrated with a comprehensive approach to weight loss.  So it is with chagrin that on PodMed this week, Rick and I discuss results of a JAMA study showing that fitness trackers not only didn't help people lose weight, the group using them did worse with regard to weight loss than the group who didn't use one! Yikes. What happened?

A total of 471 overweight and obese people 18 to 35 years of age were recruited to this long term study. A low calorie diet, increased physical activity, and group counseling sessions were all employed initially, with telephone counseling sessions, text messages and access to a website with study materials added at the six month interval.  At the six month point half the participants were supplied with a fitness tracker and web interface, while the standard intervention group utilized a website for self-monitoring.

The study continued for two years, with about three-quarters of participants completing the study.  Those who used the fitness tracker lost about 3.5 kg ( 7.7 pounds)  compared to the standard group, who lost 5.9 kg ( 13 pounds) on average.  Hmmmm.  Rick speculates that the robust support received by the standard intervention group has something to do with this outcome, but I'm really at a loss to explain it. Thoughts welcome.

Other topics this week include introduction of potentially allergenic foods into an infant's diet, also in JAMA, a look at beta blockers after heart attack in the BMJ, and in the Journal of Clinical Oncology an analysis of prostate cancer risk following vasectomy.  Until next week, y'all live well.

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iStock_60596186_MEDIUMThose of us of a certain age, and the young at heart likely remember Mary Poppins, who crooned, "just a spoonful of sugar makes the medicine go down..."  Now such a chant is likely to be met with boos from the medical establishment, as the august Circulation has weighed in on how much sugar a child should consume, and folks, as Rick and I discuss on PodMed this week, it's much less than a spoonful per day at least for the very young.

Keeping in mind that cardiovascular disease remains the number one cause of death worldwide, a writing group assessed all the available literature relative to the consumption of sugar in children and the development of said disease, or more properly, diseases that often result in cardiovascular outcomes. These were subsequently divided into five well-known conditions: diabetes and insulin resistance, obesity, high blood pressure, nonalcoholic fatty liver disease, and lipid aberrations. The inescapable fact emerged that such health problems developed at levels of sugar consumption far below what is currently recommended, specifically, depending on which guidelines are consulted, 6-10% of calories consumed per day.  Current NHANES data reports about 16% of calories for children consumed each day are from sugars.

What about changing such entrenched behaviors?  The study recommends that since no one really knows how much sugar is deleterious to the health of a child, things are simple:  no added sugar at all for children 0-2 years of age.  Children and adolescents may be able to consume approximately 6 teaspoons of sugar per day, but beverages should be limited to one eight ounce portion or less per week.  The committee opines that it wouldn't be bad for adults to get on board with these reductions either, since our worldwide problem with obesity continues unabated.

Other topics this week include a look at breast density and mammography frequency in Annals of Internal Medicine, and two from NEJM: a potential new treatment for essential tremor and the predictive value of genetic testing with regard to adjuvant chemotherapy in women with early breast cancer.  Until next week, y'all live well.

 

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iStock_27891038_MEDIUMHutterites have been figuring large in the medical research lately, with PodMed two weeks ago featuring a study on asthma and allergy in children in this community, while this week on the podcast Rick and I talk about a study comparing intramuscular flu vaccine to intranasal vaccine in two groups of these folks, as published in Annals of Internal Medicine. So we extend our thanks to the Hutterite people for agreeing to be a part of studies that advance knowledge for us all, in this case relative to flu vaccination methods.

The study was conducted over three influenza seasons among 52 Hutterite colonies in Alberta and Saskatchewan, Canada. Almost 1200 children ranging in age from 36 months to 15 years received a vaccine, while just over 3400 community members did not.  The study was designed to assess whether the live intranasal vaccine was superior to the inactivated intramuscular vaccine in providing protection for both the community (herd immunity) as well as the children.

Children were randomized to either the live attenuated intranasal flu vaccine against three strains of influenza, or to an inactivated vaccine containing the same three strains. About three quarters of the children in each group received the vaccine. There was no difference in the rate of influenza infection among either those vaccinated or persons in their community, with the authors concluding that there was no advantage to the intranasal live attenuated vaccine with regard to community protection.

I point out to Rick in the podcast however, that it also appears that the vaccine, marketed as FluMist, did work as well as the intramuscular vaccine, and may call into question the CDC's action of late June panning the intranasal vaccine for the upcoming flu season.  While I really did not like the one administration of this vaccine I received I am sympathetic to children who really don't like injections at all.  Time will tell, I suppose, on whether intranasal vaccines will return to favor.

Other topics this week include scrutiny of beta blocker use in those who've had stents in the Journal of the American College of Cardiology, a new osteoporosis drug in JAMA, and an association between Tylenol use during pregnancy and behavior problems in offspring.  Until next week, y'all live well.

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iStock_17258462_MEDIUMCan receiving text messages help improve a person's choices relative to reducing diabetes risk behaviors?  That was the central question addressed by a study Rick and I discuss on PodMed this week, as published in a journal we've never talked about before: the Journal of Medical Internet Research.  We're betting we will be hearing more from this journal as all over the world, the potential for using internet and mobile technologies to monitor, support and change choices that affect an individual's health is being undertaken, especially if the results equal or surpass those seen here.

This study was conducted in India among a cohort culled from a million Nokia phone subscribers. The study subjects received 56 text messages over the course of six months in their choice of 12 languages. The messages targeted fruit, vegetable and fat consumption and endorsed more exercise. A control group received no messages.  At the end of the study message receivers were more likely to consume more fruits and vegetables and attempt to reduce fat intake, although there was no improvement in exercise. The authors conclude that in low and middle-income countries, where diabetes risk is quite high and so is mobile phone access, such a strategy could have a great impact on new cases of diabetes in the future.  Questions we'd like to see answered would include the impact over a longer period of follow-up and the durability of results, but for now, we're encouraged.

Other topics this week include the impact of exercise on five common health conditions in the BMJ, ICU stays versus those on a medical floor with regard to outcomes in JAMA Internal Medicine, and insurance status and outcomes for two cancers in Cancer.  Until next week, y'all live well.

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iStock_6759635_MEDIUMWhat can Amish and Hutterite people teach us about genes, the environment, and the development of asthma?  Lots, according to a study Rick and I discuss on PodMed this week and published in the New England Journal of Medicine. This study looked at two groups of people who originally emigrated to the US from geographically similar central European areas and share the majority of their genes. They ultimately settled in two different farming communities in Indiana and South Dakota, respectively, and their farming practices are also distinct.  The Amish have generally small, family run operations while the Hutterites tend to work large corporate farms, thus their exposures are quite different.

It turns out the prevalence of asthma among the Amish children is just over 5% while  over 21% of the Hutterite children develop the condition.  Allergic sensitization is also divergent: 7.2% in the Amish versus 33.3% in the Hutterites.  By employing a mouse model, this study was able to demonstrate that dust from Amish homes inhibited airway reactivity and cellular proliferation characteristic of allergy. Researchers conclude that early and presumably sustained exposure to this allergen mix engages the innate immune response that is ultimately protective against asthma and allergy. Rick and I agree that precise identification of the allergens as well as timing of exposure may provide a likely therapeutic strategy to prevent asthma.

Other topics this week include a look at obesity, diabetes and cardiovascular events among a group of identical twins with divergent weights in JAMA Internal Medicine, off site cardiac monitoring in at risk patients in JAMA, and in MMWR, a look at preparedness nationally for preventing Zika-related fetal abnormalities.  Until next week, y'all live well.

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iStock_70075667_MEDIUMDid you know that the health impact of sitting at a desk job for eight hours a day is as deleterious as smoking cigarettes or being obese?  That's according to a Lancet study Rick and I discuss on PodMed this week, but there is good news:  you can offset your desk jockey occupation by exercising moderately 60-90 minutes five days per week.  Enough said!  Get out there and exercise.  But first let's take a look at the data.

This study was a meta-analysis including over 1 million people for whom sitting time and mortality statistics were available.  People were divided into four groups based on their physical activity and sitting time, with the reference group sitting less than 4 hours per day and reporting the most activity.  Compared with this group, those who were the least physically active experienced mortality rates 12-59% higher than those in the reference group. By contrast, those who were physically active but also sat for prolonged periods had no increase in mortality rates.  The authors conclude that physical activity was protective against the effect of prolonged sitting.

Rick and I both speculate on the ramifications of this study, wondering if it helps further inform an appropriate daily dose of exercise, something many professional societies have been circling around for years. Clearly this study suggests it's more exercise than has often been cited.  We also wonder if prolonged exercise one day a week, such as Rick's cycling behavior, counts against the daily totals or if more or less daily exercise is needed.  No doubt more research coming, but for now, we agree, almost everyone needs to move more and sit less.

Other topics this week include two others from the Lancet on depression and behavioral activation therapy, and the global economic burden of inactivity, and in JAMA, the USPSTF's recommendations on skin cancer screening.  Until next week, y'all live well.

 

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