Intensive lifestyle intervention for folks with type 2 diabetes fails to reduce cardiovascular events and death from same, a study Rick and I discuss this week on PodMed and published in the New England Journal of Medicine sadly concludes.  Results were so lackluster in fact that the study was stopped early! Sigh. A sacred cow has been slaughtered, and I for one am sorry.  Let's take a closer look at the carnage.

Look AHEAD (the name of the study) researchers investigated whether weight loss and increased exercise in people with a BMI greater than 25, who were also using a medication for glucose lowering, some of whom were on insulin, and were 45 to 75 years of age, among other study entry criteria, reduced cardiovascular events or death from cardiac problems. The intention was to follow these participants for up to 13.5 years, and they were recruited from 16 clinical sites in the United States. 5145 patients were randomized to either intensive intervention with caloric restriction and exercise about 3 hours a week, or usual care involving diabetes support and education. Outcome measures included death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for angina.

The study was stopped early when an interim analysis revealed that the intervention was futile with regard to the outcome measures. At a mean follow-up of 9.6 years, 418 subjects in the control group and 403 of those in the intervention group had experienced one of the primary outcomes. Wow, what a disappointment! What about other measures of potential benefit?  Turns out the intervention group did experience greater weight loss, a greater reduction in waist circumference, a lower hemoglobin A1c, improvements in blood pressure and other measures of cardiovascular risk except low-density lipoprotein levels.  The intervention group also used fewer antihypertensive medications, statins, and insulin. Yet these did not translate into fewer cardiovascular events, a finding I find nearly incomprehensible. Does this mean we can just back off and tell folks with type 2 diabetes to simply take their medicines and otherwise do as they like ?

Rick and I agree that although the hard endpoints were distressingly unchanged, the other aspects of life for the intervention group, specifically being able to take fewer medicines, are worth advocating, and we're sticking with our story.  Things like arthritis and mobility will also be positively affected by weight loss and exercise, and additional quality of life measures would no doubt be improved.

It would be remiss of us, of course, not to mention that the very best strategy for type 2 diabetes is prevention, and that's where we'd put our money.  If obesity is prevented by a multipronged and societally sanctioned approach, type 2 diabetes incidence will be dramatically reduced.  We're also willing to bet that those cardiovascular outcomes would also occur much less frequently.

Other topics this week include an implantable insulin pump that detects nighttime blood sugars, also in NEJM, strategies to lower costs in high risk Medicare patients in JAMA, and advanced treatment use in men with low risk prostate cancer in the same journal.  Until next week, y'all live well.

 

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It's likely a pretty sure bet that we've all heard of heart attacks, known in the medical parlance as myocardial infarction.  Some of us may have even had such an experience or borne witness to someone else having the experience, which is often dramatic, involving pain and a host of other unpleasant sensations, and prompting people to seek medical help quickly.  Not so for brain attack, more commonly known as stroke, or cerebrovascular accident (CVA) in medicalese. Symptoms of blood flow interruption to the brain may appear more gradually, be mistaken for something else, or seem mild or transient enough to ignore and hope it goes away. Yet a study Rick and I discuss this week on PodMed eloquently illustrates why brain attack is every bit as emergent as heart attack, as published in JAMA.

Data from almost 1400 hospitals participating in the 'Get With the Guidelines-Stroke Program,' from April 2003 to March 2012 were analyzed, comprising 58, 353 patients treated with tissue plasminogen activator or tPA within 4-5 hours of onset of stroke symptoms. Onset to treatment, abbreviated OTT time was calculated for all of the patients, with 9.3% treated in the 0-90 minute window, 77.2% in the 91 to 180 minute window and 13.6% in the 181 to 270 minutes group. The most dramatic finding of this study was that each 15 minute decrement in OTT time was inversely related to likelihood of surviving to discharge, being discharged to home rather than a long term care facility, and ability to walk, so the faster you were treated the better your chance of achieving these important outcomes.  Faster use of tPA also reduced the likelihood that an intracranial hemorrhage would occur.

Other noteworthy facts about this study included the observation that patients arriving by ambulance were more likely to receive tPA faster, and if they came during normal business hours this was also true.  Clearly, these are findings to which the medical establishment should pay heed: centers of excellence with regard to stroke should be sensitive to after hours care as well as how patients arrive.  One no-brainer is that patients with more severe symptoms of stroke got tPA sooner.  Ah, duh.  We'll call that increased index of suspicion.

This study clearly underpins observations regarding the utility of tPA and its use in ameliorating sequelae of stroke as well as death from CVA.  It is incumbent upon all health professionals to educate people around them about the signs and symptoms of stroke and the need to seek immediate medical care, even at the risk of being proven wrong.  Research being conducted here at Johns Hopkins as well as other medical centers continues to expand and refine criteria and safety parameters for using tPA and at this point, it sure looks like there is no question it can be very, very helpful, but only if the patient gets into the system and then is correctly diagnosed and treated.

Other topics this week, also in JAMA, include using MRI to assess infection after steroid injection for low back pain and autoantibodies in type 1 diabetes, and in Annals of Internal Medicine toxicity with concomitant use of statins and certain antibiotics.  Until next week, y'all live well.

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Do you have a favorite song, band, orchestra, genre of music?  Recall the last movie you saw and the profound effect music had on evoking emotions related to the film.  The power of music is unquestionable, and it's occupied an important place in human history.  Small wonder then, we opine this week on PodMed, that music has been shown to be helpful to folks who are intubated in the ICU, as published in JAMA.  Here's what happened in the study:

A total of 373 patients were randomized to one of three interventions:  patient-directed music (naturally with the acronym PDM), noise canceling headphones, or usual care.  The PDM was selected by the patient with the assistance of a music therapist and could be listened to at their discretion while on mechanical ventilation in the ICU. Headphones were also available at the patient's discretion. The goal of the study was to determine whether analgesic and sedative use could be reduced among conscious patients who were intubated since these medications are associated with a host of negative side effects and outcomes, including slowed heart rate, lowered blood pressure, reduced gut motility, immobility, weakness and delirium.  Unrelieved anxiety and increased stress may give rise to short term problems with recuperation as well as post-traumatic stress disorder once discharge has taken place.

Those patients who were randomized to the music arm of the study experienced a 38% reduction in the use of sedatives and a 36% reduction in sedation intensity.  The music group listened almost 80 minutes per day, compared to 34 minutes per day of noise-canceling headphone use. The patients were studied for a mean of 5.7 days.  Both PDM and noise canceling headphone groups reported less anxiety although the PDM group reported a greater reduction than the headphone group.  Hmmm.  Sounds like (no pun intended) use of patient-directed music should be employed immediately for those patients who must be intubated and are conscious in the ICU.  Its advantages are multiple: it's inexpensive, it's easy, it gives the patient a bit of control over their environment where such control is apparently and sadly lacking, and it appears to reduce the need for medications that are known to have a host of side effects.  It also doesn't interfere with the working aspect of the ICU, since music listening isn't disruptive and doesn't get in the way.  I can envision a day where when patients enter the hospital they are queried on their music preferences much as they currently are on religious preferences.  I would even go so far as to suggest that we should advocate for this practice right now, even in the absence of objective evidence (GASP!) and use headphones and preferred music in every patient in the ICU.  That's in deference to abundant evidence suggesting that even when people are apparently unresponsive they are still aware on some level, and strategies to alleviate anxiety could bear fruit, as well as give family members something to do to help their loved one.  Just an idea.

Other topics this week include predicting acute exacerbations of COPD with inflammatory markers, also in JAMA, the CDC's look at MERS, and the consequences of childhood cancer treatment in adults, back to JAMA.  Until next week, y'all live well.

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Skin cancer considerations notwithstanding, many if not most of us contemplate use of sunscreens to reduce the signs of aging to our skin, as attested by the fact that anti-aging remedies such as creams, lotions and the like accounted for several billion dollars of purchases last year. Yet just how effective is use of sunscreen for reducing skin aging? That's what Rick and I discuss on PodMed this week, based on a study in Annals of Internal Medicine.  The results may convince even me to slather the stuff on daily.

Investigators from Down Under (aka Australia) recruited over 1600 volunteers to be randomized into four groups:  one used daily broad-spectrum sunscreen, another did the same with the addition of oral beta-carotene supplements, one did the sunscreen and an oral placebo, and the final group used sunscreen as the spirit moved them.  The sunscreen using groups were asked to apply the lotion to their head, neck, arms and hands daily in the morning, and to reapply if they went swimming, sweat profusely, or spent more than a few hours outside. Participants were followed from 1992 to 1996 and all were younger than 55 years of age at recruitment.  In addition, each had assessments of their skin performed using silicone-based skin surface replicas taken from the back of the left hand, so-called 'skin microtopography.' These impressions were taken at baseline and study completion.

Periodically during the 4 year study period study subjects were queried on adverse events and adherence to the sunscreen regimen. Data on smoking habits and sun exposure was also gathered at intervals.

Only the daily sunscreen group showed no additional signs of photoaging as assessed by microtopography at four years of follow-up.  This group was 24% less likely to show signs of photoaging as compared with the discretionary sunscreen use group.  So for those fountain of youth seekers, does this mean sunscreen is the answer?  Maybe, but one thing is known from this study: beta carotene provided no additional benefit with regard to avoiding sun damage to skin, so that at least can be given a miss.

What about the ongoing debate regarding SPF and UVA and UVB wavelengths of light and protection against them?  Sunscreen products available in the US are limited in some of the claims they make with regard to protection, for example, they can no longer use 'waterproof' and must instead use 'water resistant' as well as admonish users to reapply after swimming, and they must identify 'broad spectrum' coverage for UVA rays.  As far as SPF is concerned, the authors of this paper make the point that people may be misled by higher SPF numbers, and stay out in the sun longer or fail to reapply, both no-no's when it comes to protecting skin.  Anyone for a public health campaign to advocate sunscreen application along with flossing and tooth brushing? That may very well be the only way I'm likely to remember it.

Other topics this week include a look at various vegan diets and their impact on mortality in JAMA Internal Medicine, and two from JAMA: metabolic surgery for diabetes and the health effects of fructose.  Until next week , y'all live well.

 

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Menopause seems to be a staple for comedians and a recurring topic for myth and embarrassment among many, with little in the way of authoritative research discerning best management practices for healthcare providers or women making their way through this stage of life.  Now comes a document Rick and I discuss on PodMed this week,  issued by the British Menopause Society and taking a comprehensive look at the literature relative to hormone replacement therapy, or HRT.  As I comment in the podcast, recent research here at Hopkins by Wen Shen and colleagues demonstrates it's not a moment too soon, as even residents in obstetrics and gynecology nationally are sadly uniformed about menopause, although the average woman will spend almost a decade of her life in this transition and many will live a third of their lives after having passed through menopause!  Clearly an area where clarity is needed.

The British Menopause Society steps into the fray regarding HRT with a frank admission that confusion surrounds the issue, particularly in light of findings from both the Women's Health Initiative and the Million Women Study.  These studies scared the majority of women who were taking HRT with the specter of increased risk of cardiovascular disease, breast cancer and death, and caused many physicians to advise women not to take hormonal therapies.  Since then, reanalysis and additional information have rendered the original conclusions alarmist, with this paper broadly advising that each woman and her provider should assess her individual situation and constellation of risk factors, her symptomatology and comfort level, then make an informed choice.   In any case HRT should be used at the lowest possible dosage for the shortest period of time.

Women who still have a uterus should take progesterone in addition to estrogen, and therapy is ideally begun before a woman reaches age 60. Topically applied therapies can be considered for specific circumstances rather than oral medications.  The authors acknowledge that there is a two to four-fold increased risk of thromboembolism with the use of oral HRT, with the highest risk in the first year of therapy. They conclude that the risks for various types of cancer may be either elevated or reduced depending on the study examined, and that benefits or effects with regard to Alzheimer's disease, osteoporosis, skin health or the host of other issues women face as they age are still being discerned but may be positive.

Rick and I agree that we'd be much happier with the document if it also addressed exercise, other types of lifestyle changes, and use of antidepressants as a means of controlling hot flashes in greater detail, as these may be less potentially problematic than HRT, but we are glad to see this assessment and hope it will shed light on this issue for women and healthcare providers alike.

Other topics this week include medical emergencies on airplanes and universal MRSA decolonization for folks in the ICU in NEJM, and what to do about your anticoagulants if you're having a procedure in Neurology.  Until next week, y'all live well.

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Should people who are on ventilators in the ICU be placed on their backs or their stomachs?  In the medical vernacular that would be supine (face up) or prone (face down), and at first glance it really seems like such an academic question, as Rick and I discuss on PodMed this week, and that's because of course nearly everyone we've ever seen in an ICU is face up, or supine, thus allowing medical personnel easy access to tubes and drains and EKG leads and all those trappings of intensive medical caretaking.  And anyone who's visited someone in an ICU wants to see their face, not the back of their head.  So what's with this study in none other than the august New England Journal of Medicine?

'Prone Positioning in Severe Acute Respiratory Distress Syndrome' proves it's our bad.  Turns out that it has been known for some time now that when people have severe acute respiratory problems, being placed in a prone position improves oxygenation and may reduce ventilator-induced lung injury, yet such observations in previous research did not translate into better outcomes.  This study prospectively randomized adults with severe acute respiratory syndrome who had been intubated for less than 36 hours and whose oxygen saturation and tidal volume indicated considerable compromise to be placed either supine or prone.  A total of 466 patients were randomized, with 237 ultimately in the prone group and 229 in the supine group.  Those receiving prone ventilation were required to remain in that position for 16 hours a day.

The differences in outcome were striking.  The 28 day mortality for those who received prone ventilation while in the ICU was 16.0%, contrasted with 32.8% among those in the supine position.  The unadjusted mortality at 90 days was 23.6% in the prone group versus 41.0% in the  supine group, and those in the prone group also experienced fewer cardiac events.  Hmmm.  Seems like a win-win for prone positioning.  The authors most helpfully include a video on the NEJM website so practitioners can see how it's done; clearly experienced teamwork is needed, with three or four people required to successfully reposition the patient, but it does look fairly straightforward.  As I comment in the podcast, since we know that severe respiratory compromise is one of the features that accounted for the staggering death toll in the 1918 flu pandemic, I for one am glad that investigators are attempting to assess how to achieve the best outcome under the circumstances. It reminds me of that adage "prepare for the worst and hope for the best" as we're all watching for the emergence of another severe flu.

Another take home message that seems clear is that a priori assumptions about best practices are suspect at best.  As we see more evidence emerging about the dangers of transfusions, maybe even those with hematocrits in the basement should be left to their own devices.  Ditto for tight management of glucose in folks in the ICU, immobilization on backboards before transport of those injured in the field and transported to the ICU, and on and on...sacred cows are being felled in all directions, lending credence to our new mantra: evidence-based medicine.  Stay tuned.

Other topics this week include implanted cardiac defibrillators and sports risk in Circulation, short term versus longer term steroid use in COPD in JAMA, and assessing the benefit of prostate cancer treatment in Annals of Internal Medicine.  Until next week, y'all live well.

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"Let them eat cake!" is often attributed to Marie Antoinette, but a quick search reveals it was actually Rousseau who first penned the phrase in his tome 'Confessions.'  The circumstances were the same as the legend, however, as it was an imperious princess who extolled the virtues of cake (brioche) when bread was not available for the peasantry.  Let there be no confusion, then, that let them eat bugs was first heard on PodMed, in reaction to a paper Rick and I discuss by the United Nations Food and Agriculture Organization, indeed advocating the consumption of insects to stem the tide of world hunger, both current and looming.

In a publication entitled "Edible insects: Future prospects for food and feed security," this UN committee lays out the argument for not just opportunistic gathering of native insects but actual farming of various species and deliberate utilization of them as a food source for people and animals.  The 200-plus page report begins with a sobering thought: by 2050 there will be about 9 billion humans resident on planet Earth, but to sustain this population food production will need to double. Clearly there is not enough arable land to achieve this, and with the additional complications of global warming and water shortages, the challenges are huge. Yet there is a vast, underutilized source of food right beside us in the form of insects.

Right now, about 2 billion people worldwide already consume insects as part of their normal diet. By far the most popular type is beetles, followed by caterpillars.  Together these two comprise almost half of all insects consumed.  They're followed by grasshoppers, crickets and locusts, then cicadas (East coast US residents, take notice!)  leafhoppers and the like.  A host of other insect groups make up the remainder. The practice of eating insects is called 'entomophagy' with obvious Latin roots for the nerds among us.

What are the health consequences of eating these creatures?  Turns out they're a lot more nutritious than you might think, offering a beneficial combination of fiber, protein, vitamins, minerals, and fats, including omega-3s, those darlings of the cardioprotective world.  One question I have is cooking the beasties:  I  really want to know if their insides become more solidified with cooking, much like shrimp, and then do you peel them before eating?  Any insect recipes our listeners/readers would like to share are most welcome and guaranteed to be posted!

How about cultivation of insects, or is it husbandry? Especially how about their potential for conveying disease to humans when they're grown in the bug equivalent of a feeding lot? Rick points out in the podcast that several types of insects are commercially grown today, such as honey bees and silk worms, and that large scale interest in such a project would no doubt accelerate development of techniques and tools for growing other types of bugs. With regard to their potential to transmit disease, right now such a likelihood is low, and is especially attractive when one considers how important both poultry and pigs are as reservoirs of human pathogens.  Finally, the report considers the 'ick' factor, and opines that communication can help.  We sincerely hope we can assist with that one, and Rick at least has committed to trying any insect dish offered to him.  Yum.

Other topics this week include a new therapy for hepatitis C in the New England Journal of Medicine, cash for health programs in developing countries in the Lancet, and long term outcomes from pelvic prolapse surgery in the Journal of the American Medical Association.  Until next week, y'all live well.

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We've all seen it happen: a child who's sucking on a pacifier drops it on the floor, and the person who's minding the child retrieves the device, pops it into his or her own mouth and squishes it around, then places it back into the mouth of the waiting child.  Hmmm.  A bit disgusting when you stop to think about it, but as any parent knows, also the most expedient way to make sure an infant or toddler can be kept under control in public. Hardly seems like the stuff of scientific scrutiny, does it?  Yet as Rick and I discuss on PodMed this week, there it is- a study in Pediatrics examining the benefits, yes, that's right, the benefits, of such a practice.  What exactly did this study do?

A birth cohort of 184 infants in Sweden were followed for up to 36 months.  The children were assessed for clinical allergy and sensitization to both foodborne and airborne allergens with development of asthma, eczema, or sensitization as demonstrated by IgE levels by a pediatric allergist at 18 and 36 months of age.  Parents kept a diary of data relative to the infant, including characteristics of the home, presence of siblings, animals, when the child was weaned, when solid food was introduced, and symptoms suggestive of developing allergic conditions.  These data were gathered from the parents by means of a structured telephone interview at 6 months.  Also queried was the method of cleaning the child's pacifier: boiling, tap water, or parental sucking.  Respondents could choose more than one option, and as Rick quips in the podcast, those of us who are parents of more than one child likely would have said boiling for our firstborn, followed by tap water rinses for the second child, and finally, a third child would be fortunate to have any method of cleaning employed at all!

The study found that about half of these parents admitted to using the sucking method to clean their child's pacifier, and those children were significantly less likely to develop asthma, allergy or IgE sensitization, or eczema at 18 months, and protection against eczema remained at 36 months of age. Moreover, an assessment of oral flora revealed that those children whose parents did not use sucking to clean their pacifiers had markedly different flora than their parents, which the authors suggest may be one mechanism of protection: parental flora would broaden the exposure of the infant's developing immune system and perhaps inoculate against inappropriate allergy development.

Last week in both this blog and on PodMed, we discussed a study related to immigrant children and their allergy status.  Both this study and that one seem to lend more support to the hygiene hypothesis, that idea that early exposure to a host of allergens somehow prevents the immune system from responding to things like ragweed later on in life.  While the evidence is accumulating, for now it seems okay for parents to continue sucking their children's pacifiers, and for those of us who may look askance at the practice to simply look the other way.

Other topics this week include a lack of benefit seen with some supplements with regard to managing macular degeneration in JAMA, and in the same journal a look at preventing inappropriate shocks with implanted defibrillators.  We also discuss the lung cancer screening guidelines in Chest.  Now, as promised in the podcast, here's a look at a wonderful, faithful listener who's of great help to Rick and me every week and his crew in Canada: thank you, Tom, for all you do- your students are lucky to have you:  Until next week, y'all live well.

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More and more children in the US are developing allergies, and their close cousin asthma.  While some allergies are inconvenient and unpleasant, others are actually life-threatening, as asthma can also be, but so far, no one has been able to come up with an explanation for why we're seeing this increase.  This week on PodMed, Rick and I discuss an intriguing study in JAMA Pediatrics that adds one more piece to the puzzle in sorting this out.

Data from the National Survey of Children's Health including almost 92,000 participants from households with one or more children younger than 18 years of age was crunched.  One child from each household was randomly selected and parental interviews were conducted.  The data set was weighted to be representative of all noninstitutionalized children younger than 18 years of age nationally.

Asthma history, and the presence of atopic dermatitis or eczema, hay fever, and food allergy were queried. The child's birthplace was recorded as were parental birthplaces. For children born outside the US the length of time they were resident domestically was determined.

One in five children born outside the United States had any history of allergic disease, while almost 35% of those children born domestically did.  Children whose parents were born outside the United States had a lower risk of developing allergic disease: 18.2% versus 33.4%.   Most interesting of all, at least to me and Rick, is the fact that when children immigrate to the US their risk of developing allergic disease remains lower at 1-2 years post-arrival, but after 10 years their risk of any allergic condition is the same as those children born domestically. Well.  Does this mean that when children are resident abroad they are exposed to more allergens that direct their immune systems in such a way that garden variety molds, grasses and the like are simply too inconsequential to respond to? This would be  in support of the so-called 'hygiene hypothesis,' wherein exposure to parasites and other stimuli to the immune system effectively prevents said system from responding to other, possibly molecularly similar antigens but which don't really represent a threat.  In further support of this idea, we recollect on PodMed, is a study we covered a couple of years ago where children exposed early on to cats and dogs developed fewer allergies and asthma later in life, and yet another examining allergic diseases among those raised on farms, with similar results.  As I opine in the podcast, new parents might perhaps take this to heart and adopt one of the multitude of animals in shelters if they're not pet owners already.

There is an alternative explanation to migration to the US and subsequent development of allergies in kids, and that's the possibility that domestically, children are exposed to something not found in such high density elsewhere in the world that then gives rise to allergic conditions.  Fast food? SUVs? A preoccupation with perfect dentition? The possibilities are endless but also worth considering.  For now, if this provides more possibilities for an explanation that would no doubt benefit the legions of allergy sufferers everywhere.

Other topics this week on PodMed include HIV screening guidelines in Annals of Internal Medicine, and two from NEJM: whether surgery helps for cartilage tears in the knee, and a common antibiotic and cardiovascular risk. Until next week, y'all live well.

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H7N9 is shorthand for the current avian flu virus infecting and often killing people in China, and it's gotten the attention of public health types worldwide, Rick and I discuss on PodMed this week.  A study in the New England Journal of Medicine chronicles what is known about the virus at the moment, while CDC recommendations and updates published this week highlight recommended treatment for H7N9 infection.  So what is known?

First of all, H7N9 is a truly novel influenza virus of avian origin.  While H7 viruses arising from birds have been seen in human infections previously, this is the first N9 subtype identified.  In contrast to previously isolated H7 viruses, which usually cause mild conjunctivitis or moderate respiratory symptoms, this isolate is quite virulent.  The NEJM article describes the clinical course for three patients infected as presenting with high fever and cough, rapidly progressing to a need for intubation (declined by one patient) and death.  As of 4/25/ 2013, China has reported a total of 82 confirmed cases of this type of influenza, with 77% of them having had some type of bird exposure, either to live birds or dead ones.  Live birds can shed quite a lot of the virus and spread it in their mucus or droppings, and unfortunately, in contrast to bird flu isolates seen in the past, the birds themselves don't appear sick when infected. Sickly appearance or not, China has begun culling efforts of its poultry to attempt to limit spread of H7N9.

So what about that hallmark of pathogenicity and pandemic potential, human to human spread? Clearly, the virus hasn't yet acquired this ability to any great degree as so far, infections seem to be limited.  However, the study does point out that in two cases in China, human to human transmission cannot be ruled out, and historical data demonstrate that influenza viruses can and do 'learn' to become more efficient in their person to person spread.

Now, what about treatment?  The good news is the virus continues to be susceptible to oseltamivir (Tamiflu) and zanamivir (Relenza), and the CDC guidelines recommend their use even outside of the 48 hour window since symptom onset usually observed.  Treatment should be initiated at the same time as testing. 

Vaccine candidates are being developed apace, with most manufacturers predicting six weeks or so before such a vaccine would be available.  As Rick points out in the podcast, that old public health standby, isolation of cases, is being employed in China, and will hopefully limit spread of the infection.  Our modern twist of air travel  may hamper those efforts, however, so once again, covering your nose and mouth when sneezing, washing your hands assiduously, especially in public places like airports, and seeking treatment if you suspect you may have the flu or may have been exposed remain prudent measures.

Other topics this week include the benefits of an education effort to reduce worm infections in Chinese schoolchildren and a report card on improving risk factors in those with diabetes, both also in NEJM, and a link between valproate taken during pregnancy and autism in offspring in JAMA.  Until next week, y'all live well.

 

 

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