Have you ever seen a case of pertussis, otherwise known as 'whooping cough?'  Chances are good that if you never have you may soon, since 2012 had the dubious distinction of being the year with the most cases of pertussis occurring nationally, that's about 38,000, since 1959. As Rick and I discuss on PodMed this week, pertussis is just one of a number of reportable, vaccine-preventable diseases chronicled in a retrospective analysis in NEJM entitled, "Contagious Diseases in the United States From 1888 to the Present," and many of which are increasing in incidence, mostly for indefensible reasons.

First of all, we'd both like to laud the authors of this paper for the massive investigation and data crunching represented herein. Investigators digitized all weekly surveillance reports of nationally notifiable diseases between 1888 and 2011. This represented almost 90 million individual cases, further characterized by both date and geographic location in the United States. Eight vaccine-preventable contagious diseases were selected from the dataset for further analysis: polio, measles, rubella, mumps, hepatitis A, diphtheria, pertussis and polio. For seven of these eight diseases the authors estimated the number of cases that have been prevented since the introduction of a vaccine for the disease, using the year of the specific vaccine introduction as the cutoff date.  Smallpox was eliminated from this analysis since the vaccine was introduced in 1800 and no estimate of preventive capability was therefore possible.  Interestingly, not one of the 56 notifiable diseases reported since 1888 was continuously reported during this period, which the authors attribute to "shifting public health priorities and challenges."

So what did this analysis find?  Not surprisingly, most infectious diseases prior to the development and release of vaccines had more or less predictable patterns of outbreaks and epidemics, often seasonal, followed by a period of reduced transmission.  Once an effective vaccine was introduced and used widely, that pattern was eliminated and the number of cases of each disease declined rapidly.  The authors calculate that 103.1 million cases of these infectious diseases were prevented because of the employment of effective vaccines, assuming that all of the decline in incidence before and after vaccine introduction was due to the vaccine.  As I comment to Rick in the podcast, this seems to be an unrealistically low estimate to me, and the investigators concur, citing under-reporting as one factor that likely lowered cases of reportable diseases as well as the probability that under-reporting occurred more often in the pre- rather than post-vaccine introduction period. In any case, the analysis clearly establishes vaccines as a success story and should enable clinicians to stress their virtues to the distressingly large number of parents who seem reluctant to have their children vaccinated.

Rick and I agree with the authors that persistent urban myths related to vaccination dangers to offspring must be dispelled repeatedly and public health measures supported to ensure proper vaccination, including enforcement of school attendance policies.  As a primary conduit of infection, children must be vaccinated to safeguard the health of all, especially very young infants and older folks whose immune response has declined.  Perhaps primary care physicians could employ video of a child with whooping cough to bring home the point that worldwide, almost 300,000 deaths still occur from this disease.

Other topics this week include a disappointing response to the latest HIV vaccine candidate, also in NEJM, micronutrients in early HIV infection and thalidomide for kids with refractory Crohn's disease in JAMA.  Until next week, y'all live well.

 

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Should you be taking a statin medication to control cholesterol and reduce your risk of a cardiovascular event? As Rick and I discuss on PodMed this week, according to new guidelines published in Circulation somewhat euphemistically called '2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults," many, many more people than are currently taking these medications should be. And I say 'euphemistically called' because we also agree with our colleague Michael Blaha, who quips that these should really be called statin guidelines as no other medication even receives a nod with regard to cholesterol management.  So what did these guidelines assess and what do they say?

The panel conducted a review of all the randomized controlled trials and meta-analyses of same related to atherosclerotic cardiovascular disease outcomes from January 1, 1995 through December 1, 2009. Studies were assessed and rated and data synthesized into evidence statements rated from strong to no evidence.  Additional evidence from more recent studies was also included in the discussion.  Here's what is new:

There are four main groups that would most likely benefit from statin therapy: folks with clinically evident atherosclerotic cardiovascular disease, those with an LDL greater than or equal to 190 mg/dl, people with diabetes aged 40-75 years and an LDL of 70-189, and finally, those who don't fall into the second or third groups, above, but whose 10 year risk of a cardiovascular event, including stroke, is greater than or equal to 7.5%.  If all these groups were brought under the statin umbrella, estimates are an increase of up to 100% in those currently taking the drugs.  Statin nation, anyone?  As Rick opines in the podcast, the fourth group, above, would rein in older folks with otherwise good health and nonexistent or controlled risk factors simply because their age places them in a group at risk for cardiovascular events in the next ten years.  Might be a bit of a tough sell, methinks.

The guidelines also eliminate the benchmark of LDL cholesterol as a target for therapy, because of the lack of an evidence base!  WOW!  I'll go out on a limb here and speculate that this is going to take quite some time to penetrate the collective consciousness and make sense to many primary care providers, let alone patients themselves.  Rick and I both applaud application of evidence in eliminating LDL measurement except initially, but predict that this change in particular will likely account for hours of education time on the part of clinicians to alleviate public confusion.

Finally, what about the no man's land of people whose risk may be thought of as low to intermediate yet eligible for statin therapy, but who resist? The panel rather dryly states that treatment decisions may be informed by other factors, presumably things like coronary calcium scanning, but isn't recommending same.  For those of us addicted to numbers, though, I wonder how much more utilization of these we're going to see.  In sum, then, Rick believes these guidelines are the first pass, likely to be modified, and then there's the issue of the risk calculator.  But that's another story.

Other topics this week include more studies from the AHA meeting, all published in JAMA.  These include lowering body temperature in the field in those who've had an MI, immediate blood pressure lowering in stroke, and mechanical versus manual compressions in CPR.  Until next week, y'all live well.

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What comes to mind when you think 'screen time?' I have to admit that for me, the phrase conjures up 15 minutes of fame and how long someone might remain prominent on the various media screens we are exposed to, but this week, as Rick and I discuss on PodMed, the American Academy of Pediatrics reverses that idea with recommendations for screen time for kids, that is, how much time should your children spend in front of a screen, consuming media of various types? These are published in Pediatrics.

Rick starts this segment on PodMed with querying me on how long the average 8 to 10 year old in the United States spends in front of a screen of some type, including a computer, television, smart phone, or any permutation thereof. My guess was five hours a day, but the startling figure is 8 hours per day, with teenagers spending greater than 11 hours each day in these activities.  That's even more time than they spend sleeping or at least equal to that. Such behavior is bolstered by the fact that 71% of children queried reported having a television in their bedroom, which by itself accounted for 4 hours of screen time per day. An impressive 84% of children and teenagers report access to the Internet, and 75% own a cell phone.  Disconcertingly, 2/3 of these kids report that their parents have no rules whatsoever about use of these media.  No surprise then, that recent high profile cases of web-based bullying and subsequent suicide in adolescents were not fully appreciated by parents.

Against this dire backdrop, what does the academy propose? Clearly, pediatricians and primary care physicians need to get into the act, although I would add parenthetically amongst all the other screens we keep imploring them to do.  Two questions are appropriate: How much recreational screen time does your child consume each day? and is there a television or Internet connected device in your child's bedroom? Based on the answers, docs can educate parents on the risks for obesity, substance abuse and exposure to sexually explicit material when such media can be accessed in private, and make recommendations regarding appropriate amounts of screen time relative to the age of the child. Rick opines in the podcast that he agrees with the academy in that parents should consider TV viewing with their offspring as an opportunity to share family values and not allow televisions in children's bedrooms, and I agree. Such sedentary activities should be limited, in the opinion of the academy, to less than 1-2 hours per day, and here's something that amuses me: no screen time at all for those younger than 2!  Wow, I must admit it never even occurred to me that a child younger than that would enjoy such activity! or lack thereof.

Clearly, with regard to our connected lives and media dependence, this is going to be a tough sell, but likely to reap benefits for all concerned. Other topics this week include HIV and risk of meningitis in Annals of Internal Medicine, blood pressure medications in folks with diabetes in the BMJ, and steam, NSAIDs and respiratory infections in the same journal.  Until next week, y'all live well.

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If you are a person with an existing heart condition or you're at risk to develop one (read that almost everyone as we age since as we know, cardiovascular disease remains the number one killer) you should get a flu shot, Rick and I opine on PodMed this week, based on a study examining the relationship between flu vaccination status and acute cardiovascular events in JAMA.  We freely admit that this is nothing new; we've been on the soapbox about the flu vaccine for many years now, but this study attempts to quantify risk reduction, and for the doubting Thomases out there may be just what's needed to change behavior.

This study was a meta-analysis of randomized clinical trials comprising almost 7000 patients (more than half of whom were women!) comparing influenza vaccine versus placebo in folks at high risk for cardiovascular events. Almost 40% of subjects had a previous history of cardiac problems. Mean follow-up time was almost eight months. The analysis found that indeed, influenza vaccination was associated with a reduced risk of an acute cardiac event, and that the benefit was greatest in the highest risk patients! Unquestionably an eloquent argument for obtaining the influenza vaccine.

Rick and I speculate on the mechanism by which vaccination would provide such a benefit, and devolve with much company to the inflammation hypothesis.  While a persuasive case can be made that subsequent to the actual administration of the vaccine a low level of acute inflammation often results, it seems clear that this arm of the immune response and possible small risk to folks with existing cardiovascular disease is overcome by the significant benefit seen in avoiding a much greater degree of inflammation when someone develops influenza infection. Indeed, in this study no risk of acute cardiac events was seen immediately after use of the vaccine, and the authors call for larger prospective studies to examine this very question.

The American Heart Association is clearly convinced by the existing data on risk reduction with influenza vaccination for folks at risk such that they recommend annual immunization as one means of risk reduction for cardiac events. Also very recently a new type of flu vaccine with double the amount of antigen was introduced specifically with older people in mind, whose immune responses are not as robust as younger folks and therefore may not be protective.  Finally, we also need to reiterate the fact that the Centers for Disease Control and Prevention has expanded recommendations for who should receive the flu vaccine to almost everyone, pregnant women included. It's worth noting that when you get the vaccine you're not just protecting yourself but everyone around you.  Okay, rant over.

Other topics this week include giving the pertussis vaccine (!) to teenagers and it's impact on whooping cough in infants in Pediatrics, a disappointing result for use of statins to prevent ventilator associated pneumonia in JAMA, and in Annals of Internal Medicine a look at why screening for cognitive impairment isn't helpful and likely shouldn't be done.  Until next week, y'all live well.

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Has your primary care physician talked to you about being screened for cancer? For most of us the answer is a resounding yes, since to avoid messaging about screening colonoscopy, for example, would likely require being deaf, dumb and blind, as well as residence in a cave in the Ozarks, perhaps. So virtually all of us are exposed to messaging about cancer screening of various types, raising the likelihood that if our doctors don't mention it to us we will probably mention it to them. But as Rick and I talk about on PodMed this week, do physicians reveal the potential harms of screening, including the probability of overdiagnosis and subsequent overtreatment?  That's the substance of a research letter in JAMA Internal Medicine this week, and to that, the answer is a resounding no.

Researchers engaged 317 men and women ranging in age from 50 to 69 years from across the US in an online survey querying their exposure to screening programs.  Clearly this is an age range where such exposure is likely to be high. No one included in the survey had had cancer.  Approximately 20% of the sample  had undergone one screening, 36% two screenings, 27% three, and 17% none.  Mammography was reported most often by women, and PSA testing or colonoscopy most common among men. Most damning, only 9.5% reported that their physician had apprised them of the risks of overdiagnosis and overtreatment when discussing screening tests with them, while 80% expressed a desire to be told of such risks prior to having screening.

Also concerning was the fact that among the very small number who reported being informed by their physician of these risks, the quantification of the risk was incorrect based on current literature. When confronted with the number of people who would be overdiagnosed in order to save one life, 69% of participants indicated that if that ratio was greater than or equal to 10:1 they would not undertake screening. The authors reveal that these are the ratios associated right now with both mammography and PSA testing.

Hmmm.  So what is a caring physician to do?  Clearly, being informed on current statistics regarding the harms and benefits of cancer screening must underpin any recommendations.  Admittedly, these are moving targets but also easily accessible, and it behooves providers to know them. As medicine moves increasingly toward not just involving patients in their own caretaking decisions but holding them responsible for doing so, clear and current information must be provided. The authors cite another study regarding physician awareness of current risks of overdiagnosis for mammography and PSA testing, and only about 34% and 43%, respectively, knew the correct numbers.

Patients too must attempt to become informed before undertaking screening, just as many investigate other aspects of healthcare.  As I am so fond of saying, no one is more vested in your health than you are.

Other topics this week include contamination of breast milk purchased via the web in Pediatrics, the disturbing increasing burden of stroke worldwide in the Lancet, and the impact of counseling and HIV testing in JAMA.  Until next week, y'all live well.

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Kids whose parents impose regular bedtimes have fewer behavioral problems, a study in this week's Pediatrics reports.  Well.  As Rick and I discuss on PodMed, we're not surprised, and while Rick espouses a couple of biological underpinnings that imbue this study with a potential scientific basis, I can't help but reflect on my experience as a parent and say, yes, indeed, and btw, such a strategy may also provide you, mom or dad, with precious alone time.  And that may allow you to be a better parent, too.  So what did this study do?

Data from the UK Millennium Cohort Study on 10, 230 children was used.  These kids were enrolled in the study at birth and bedtime data was collected at 3, 5, and 7 years.  Behavioral issues were also rated by mothers and teachers using a tool called the Strengths and Difficulties questionnaire, which measures conduct problems, hyperactivity, emotional symptoms, peer problems, and 'prosocial' behavior.  Teachers were only surveyed at the 7 year assessment while mothers completed the survey at the 3 and 5 year assessment as well.

A seemingly Herculean attempt was made to assess potential confounders to the primary outcome measures.  Family income, mother's age, birth order, how the mother dealt with behavioral transgressions, mother's degree of psychological distress and a host of additional factors were queried.

Not surprisingly, more children whose mothers reported poorer mental health, those with less educated parents and with lower levels of income went to bed later than 9pm or did not have a regular bedtime.  These kids were also more likely to skip breakfast, have a television in their bedroom and watch more hours of television each day. Those children were also more likely to be rated as having behavior problems by both mother and teacher.

One thing that was really fascinating about this study was the clear dose/response relationship between stochastic bedtimes and worse behavior: the more irregular the bedtime the worse the child behaved.  Additionally, when bedtimes were regularized, behavior problems were reduced and the converse was also true: those kids whose bedtimes became irregular over time developed behavior problems alongside, although this relationship did not reach statistical significance.

The authors of the study point out at least two mechanisms whereby sleep irregularity may impact behavior.  One is by disrupting Circadian rhythms, which are slow to adapt to disruptions in daily cycles, and by sleep deprivation's negative impact on homeostasis and brain maturation.  By whatever mechanism, the study informs parents that there is something that is fairly easy for them to employ that is likely to benefit their children: regular bedtimes. That, at least, is a conclusion that my daughters' pediatrician would have enthusiastically embraced.

Other topics this week include use of colchicine in the treatment of pericarditis in NEJM, which Rick now embraces as the standard of care, the prevalence of brain aneurysms in asymptomatic adults in Annals of Internal Medicine, and probiotics to prevent Clostridium difficile diarrhea in the Lancet.  Until next week, y'all live well.

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If you need to have bariatric surgery to combat obesity, the skill of your surgeon really does matter.  Duh, right? Well, as Rick and I agree on PodMed this week, many of those duh-type studies frequently turn their preconceived notions on their heads when subjected to rigorous study, so although this week's New England Journal of Medicine study on surgical skill and complications following bariatric surgery may have simply confirmed the obvious, a number of important observations were made, with clear implications for improving medical practice.  Kudos, we say, to the surgeons who agreed to participate!

Surgeons performing bariatric surgery in Michigan are registered as part of the Michigan Bariatric Surgery Collaborative, as are all hospitals where the procedure is performed.  Abundant data is gathered on each patient (about 6000 yearly) who undergoes a bariatric procedure. A total of 75 surgeons operate at 40 facilities; 20 surgeons agreed to submit a video of themselves performing a representative laparoscopic gastric bypass.  These videos were edited to remove all patient identifiers and to contain the most critical parts of each procedure only. Final videos were between 25 to 40 minutes in length and were submitted to another group of peer surgeons for review and critique.  A total of 33 surgeons from 24 hospitals performed reviews, although only 15 surgeons provided 78% of the ratings.

The primary surgical outcome measure was any complication arising postoperatively, including surgical site or wound infections, abdominal abscess, anastomotic stricture, bowel obstruction, or bleeding. Medical complications, unplanned reoperation, readmission, ED visits and mortality data were also gathered. These data were correlated with skill levels of the operative surgeon as calculated by an average, weighted measure from the peer review.

Operative surgeons were ranked in quartiles, with a complication rate of 14.5% in the bottom quartile compared with 5.2% in the top quartile. As might be expected, lower quartile ranking was associated with higher rates of infection, readmission, and all other complications.  Mortality among those patients operated by the lowest quartile surgeons was 0.26% versus 0.05% in the highest quartile.

Lowest quartile surgeons had longer operating times, but fascinatingly, there was no correlation with fellowship training in bariatric or laparoscopic surgery, or length of time in practice with lower ranking.  There was a correlation with volume of procedures, however, bearing witness to the idea that the best outcomes are seen in surgeons who do certain procedures again and again and again.

What Rick and I both like very much about this study is the path it points toward collegiality and skill improvement for surgeons, with clear applicability beyond bariatric surgery.  The authors point out that other complicated surgeries and procedures can also be improved with peer review, and they report that in Michigan, surgeons watch each other operate during site visits and videos of very proficient surgeons have been made available.  A win-win all around!

Other topics this week include antibiotics, anti-inflammatory medications and bronchitis in the BMJ, gowns and gloves in reducing infections in the ICU in JAMA, and stent placement and subsequent surgical risk in JAMA.  Until next week, y'all live well.

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Urinary tract infections or UTIs are a very common, very vexing problem for many people, most of them women. On PodMed this week, Rick and I review the fact that over 1 million, yes, that's right, 1 million hospital admissions occur yearly due to complications of UTIs, often recurrence and persistence.  It's probably worth mentioning that female anatomy is largely to blame since the urethra is so short it allows bacteria to reach the bladder without much in the way of a journey.  Add to that hormonal fluctuations, sexual activity and even athletics and it's no surprise that UTIs are so troublesome, and women don't age out of the problem.  Indeed, undiagnosed UTIs in largely female patients with Alzheimer's disease and other forms of dementia may account for combativeness and a host of other behavioral problems.  Wouldn't it be great, then, for a simple grocery store item like cranberry juice or other cranberry products to helpful?  Unfortunately, this review in JAMA clearly shows they are not, so it seems legions of women must go back to the cupboard or pharmacy and try again.

This Cochrane review took a look at 24 randomized trials with almost 4500 participants in a range of countries and medical care settings. Study subjects included children, pregnant women, people with a history of recurrent UTIs, a sprinkling of men, and people who required catheterization. Cranberry products, including juice and concentrates, tablets and capsules were compared with placebo, water, or no treatment.  Overall, no cranberry product was associated with fewer UTIs, although the products appeared safe.  Booo for those who would like to utilize self-administered interventions and become more participatory in their own care, I say.

The authors do offer an observation and a caveat about the findings of this study: it appears that adherence to the protocol was low for use of the cranberry products and the rate of study withdrawal high, so perhaps tolerating a certain amount of discomfort from a UTI precluded study completion  and a benefit might have appeared further along.  They also reveal that measurement and standardization of the purported active ingredient in cranberry products, called proanthocyanidin, was lacking, and future efforts to study the effect of cranberry products should remedy both.

In the meantime, what can someone who experiences UTIs do? Many preventive strategies use antibiotics to ward off the infection or catch it very early, and professional societies largely endorse this.  Severe, recurrent UTIs warrant evaluation by a urologist, ideally one with an interest in this problem.

Other topics this week include two new drugs for diabetes of a novel class of such medications, in NEJM, cognitive dysfunction after ICU stays in the same journal, and hormone replacement therapy follow up from the Women's Health Initiative in JAMA.  Until next week, y'all live well.

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Robots are taking over the world, anyone who's paying attention will attest.  What with robotic manufacturing, robotic pilots, even solar-powered robotic lawnmowers (!), it's a short philosophical step to the speculation that humans will soon be outmoded.  But lest we go too far in that direction, this week's New England Journal of Medicine describes a robot that exists solely to serve a human, and while it's the stuff of science fiction, as Rick and I agree on PodMed, it's quite exciting and life-altering for this person.  Rick also reveals that in almost eight years of recording the podcast, this is the first time we've ever talked about a study with an n of 1!

The subject in this study was a 31 year old man whose leg was amputated at the knee in 2009, following a motorcycle accident.  At the time of the amputation the surgeons retained the major nerves serving those muscles in the lower leg and reimplanted them in muscles in the thigh.  The reason they did this was to prevent the formation of neuromas, really painful collections of severed nerve ends that often proliferate after their target muscle has been removed, and also with an eye toward a unique prosthesis. The surgeons relied on their previous experience in arm amputations to accomplish this; they call the strategy 'targeted muscle reinnervation' or TMR and have shown that it ultimately improves the control of motorized arm prostheses.

Subsequent to the amputation investigators used electromyography (EMG) to assess the quality of signals from the nerves that were reimplanted. A grid of EMG signals from both muscles that had had the lower leg nerves reimplanted into them as well as those that had not was developed for use in robotic prosthesis control. As expected, the reimplanted muscles generated robust EMG signals, particularly when attempts to move the already amputated lower leg were made. Attempted motions had distinct EMG patterns which simplified the algorithm development for ultimate control of the prosthesis. Prosthesis control using just mechanical sensors versus the TMR enhanced system revealed the superiority of the latter, with no 'critical errors' occurring with the TMR system, which would be much more likely to result in a fall or injury.  Using this system allowed the patient to climb and descend stairs, and walk outdoors on uneven surfaces.  There's also a really cool video showing the subject kicking a soccer ball!

The TMR enhanced system was clearly superior to even the most sophisticated prostheses being used right now, with the patient reporting much better control and confidence as well as ability to transition between activities easily. Investigators suggest that further development of the grid implementing EMG signals as well as lighter, smaller and quieter robotic prosthetic limb are all improvements they're after, but everyone is feeling optimistic. I wonder if I could place my order for a robotic housekeeper? Specter of Hal notwithstanding.

Other topics this week include guidelines for medical breast cancer prophylaxis and arsenic and cardiovascular disease in Annals of Internal Medicine, and an effective drug to prevent cyctomegalovirus reactivation in people who've had bone marrow transplants, also in NEJM.  Until next week, y'all live well.

 

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Screening for colorectal cancer saves lives, and now we have even more evidence of this, as Rick and I discuss on PodMed this week, based on two HUGE studies published in the New England Journal of Medicine. So how HUGE are they?  One used the Nurses Health Study and the Health Professionals Follow-Up Study of almost 90,000 participants followed for 22 years, while the other followed just over 33,000 subjects for 30 years.  Wow!  That's a lot of data.

The first study I mentioned examined sigmoidoscopy and colonoscopy for their ability to identify and prevent deaths from colorectal cancer. While these techniques have been employed and been recommended for screening for some time, proof of their efficacy in these times of close examination of health care costs and benefits is welcome.  This study recorded whether 88,902 participants had undergone sigmoidoscopy or colonoscopy and for what purpose, over 22 years.  During that time 1815 documented cases of colorectal cancer were identified, with 474 deaths from this disease. Additional examination of the actual tumor and molecular characterization was also performed in many of the cases of colorectal cancer, with an eye toward defining those cancers that arise in people who have undergone screening colonoscopy within five years of presentation.

This study found that indeed, both colonoscopy and sigmoidoscopy do reduce deaths from colorectal cancer, with sigmoidoscopy clearly limited to cancers of the distal colon, while colonoscopy confers survival benefits with regard to proximal disease. A couple of the molecular tests revealed tumor characteristics of the faster growing lesions that may help point the way toward clinical utility.

The second study used the Minnesota Colon Cancer Control Study to take a look at the ability of fecal occult blood testing (FOBT) to reduce the risk of dying of colorectal cancer.  During the 30 years of follow-up, 732 deaths occurred from the disease. Both annual and biennial screening reduced the risk of colorectal cancer death, predictably, annual slightly more than every other year, with men experiencing more benefit than women with regard to risk reduction. As Rick and I discuss in the podcast, there's lots of reasons to feel good about this data: FOBT technology is improving all the time and most people find it an acceptable means of screening, in contrast to many folks who simply refuse to undergo sigmoidoscopy or colonoscopy.  As more molecular tests are developed and deployed, no doubt the detection capability will improve further, and perhaps we'll see even better results regarding colorectal cancer death prevention.

It's also worth noting that once someone has a negative colonoscopy, they probably don't need another for 7-10 years, so I would say to those who've been avoiding it to just suck it up and be done with it.  Clearly, those with a family history of the disease or who've had polyps removed need to be more vigilant.

Other topics this week include the benefits of bracing for scoliosis, also in NEJM, antioxidants and mortality in JAMA, and an IOM report and multiple studies in the Journal of Hypertension on the controversy surrounding salt intake and its health impact.  Until next week, y'all live well.

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