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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As any listener to PodMed knows, I am a rabid antismoking advocate and given the chance to implement only one public health mandate, would instantly abolish tobacco products of all types.  I firmly believe that subsequent generations will reflect upon ours with astonishment that something as wholly detrimental as cigarettes are actually sold and used legally. Since revoking legality is unlikely, now come two studies in the Lancet, one describing the role of e-cigarettes in comparison to other methods for smoking cessation, and the other a hard-hitting advertisement campaign undertaken by the US government for the same purpose.  After reflecting on the fact that if smoking was simply made illegal this problem would not exist, Rick and I applaud these efforts to help people make the choice to forgo smoking. Let's look at the ad campaign first.

The 'Tips" campaign was developed by the federal Centers for Disease Control and Prevention to deliver messages from former smokers that graphically depict suffering caused by smoking in real people.  Having seen a couple of the spots myself, I can attest that they most definitely underscored very deleterious consequences of smoking, including amputation and loss of the ability to speak normally. The spots were broadcast for three months beginning in March 2012 on television.  After that period, data from smokers and nonsmokers and estimated population data indicated that significantly more smokers attempted to quit after having seen the ads, and more remained nonsmokers after ceasing smoking.   The campaign was also effective in getting nonsmokers talking about the issue and recommending to smokers that they should attempt cessation.

While this appears to be a step in the right direction, the study reveals that the CDC spent $54 million on the campaign, compared to $8 billion the tobacco industry spends annually.  Talk about David and Goliath! One strategy Rick and I recommend is employing the constellation of graphic ads, including those on cigarette packaging as seen in other countries, to inform people of the dire consequences of smoking.  Now what about the other study?

Three groups of smokers who desired to quit were randomized to three groups:  one group got 16mg nicotine e-cigarettes, one group got 20mg nicotine patches, and the third e-cigarettes with placebo.  7.3% of those who used the e-cigarettes, 5.8% of those who used the patches, and 4.1% of those who received the placebo e-cigarettes were verified abstinent at six months.  Again, very interesting and thought-provoking.  Of course the rate of cessation is unacceptably low and better methods, perhaps multifactorial, must be devised.  But also fascinating that a decent percentage of those who received the placebo cigarette achieved cessation, underscoring the behavioral aspect of smoking that clearly motivates many.  Finally, Rick points out in the podcast, e-cigarettes are available OTC, as patches are not, so they may help more people to quit while keeping the rest of us free from noxious and toxic exposures due to others smoking.  Rick and I would love to hear thoughts from readers/listeners on e-cigarettes since they are garnering their share of controversy.

Other topics this week include pertussis vaccination among the very young in JAMA Pediatrics, and screening for mild cognitive impairment in the BMJ.  Until next week, y'all live well.

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Do you know what a rotator cuff is?  For those who do, fabulous!  Maybe you're a baseball fan or an anatomist.  For those who don't, this is the group of muscles and their tendons that move your shoulder joint.  When I was cutting up cadavers, we used the mnemonic SItS to remember what comprises the rotator cuff. That stands for subscapularis, infraspinatus, supraspinatus, and teres minor (that's why the t is lower case, because there's also a teres major), four muscles related to the scapula. All of them insert into the proximal part of the humerus, the upper arm bone, and along with the scapula and the clavicle, comprise the shoulder joint.  The shoulder joint itself is also rather interesting as it is really a compromise between flexibility and stability, and its flexibility may also be what accounts for the surprisingly high number of injuries and chronic problems that occur here.  As Rick and I discuss on PodMed this week, that may be as many as one in seven people older than 70, according to this paper in JAMA!  Culpa mea!  I had no idea it was so very common, and that's why I decided to write about it this week.

The paper is really an expose of what clinicians should look for and how they should evaluate people who come to them complaining of shoulder pain, and that's between 7 and 26% of the population at any one time, based on extensive meta-analysis.  The authors state that complaints about pain in this joint are the third most-common reason people seek medical help for a musculoskeletal problem, and they use the acronym RCD, for rotator cuff disease, to describe it.  Wow.  It's even a disease!  In an interesting series of case studies, video and illustrations, they delineate the different types of injuries or chronic problems that comprise RCD and how to distinguish them one from another.  Rather than do so here I'll simply refer clinicians to the article, but the good news is, they're all low-tech and can be accomplished in an office visit.

The major symptom of RCD is pain, in particular when the arm is raised overhead. In their extensive discussion the authors indicate that while many people are referred to specialists for evaluation, their assertion is that with practice, primary care physicians should be perfectly capable of evaluating RCD using their algorithm.  That's good news for the large number of folks with RCD, who might not have to shop their injuries to find out what's wrong.  One thing I would like to have seen in the article is what people can do about it once they're diagnosed, but I guess that's a topic for another article.

Other topics this week include screening for peripheral artery disease or PAD in Annals of Internal Medicine, steroid injections for carpal tunnel syndrome in the same journal, and overdiagnosis of thyroid cancer in the BMJ.  Until next week, y'all live well.

 

 

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Coronary artery bypass grafting, known in the medical parlance as 'CABG,' is often a very big operation but one with lifesaving potential for folks who have lengthy and/or multiple blockages of their coronary arteries, which supply the heart muscle itself.  Since its inception some 50+ years ago, various modifications of CABG have been developed and attempted, including so called 'off-pump' surgery, where the heart isn't stopped to allow the new vessels to be sewn in place.  Now comes a novel idea, at least to me, that Rick and I discuss on PodMed this week: remote ischemic preconditioning prior to CABG, as appears in the Lancet.

So what in the world is remote ischemic preconditioning?  Remote refers to a body part far from the heart, ischemic refers of course to drastically reducing the blood supply to that body part, and preconditioning is undertaking this strategy prior to the CABG operation.  In this study 329 patients who were scheduled to undergo first-time, elective cardiac bypass surgery of three vessels were randomized to remote ischemic preconditioning or not.  Those who underwent preconditioning received three consecutive inflations of a blood pressure cuff in the left upper extremity for five minutes duration, followed by five minutes of reperfusion, where the cuff was deflated and blood allowed back into the arm. These cycles took place after anesthesia induction.

The main outcome measure was cardiac troponin, an indicator of heart muscle damage, in the first 72 hours after surgery. Mortality differences between the two groups were also compared.  Cardiac troponin measured an average of 266 ng/ml in the treated group versus 321 ng/ml in the control group.  The difference persisted and reductions in all-cause mortality were also seen at the conclusion of 4 years of follow-up.  The authors conclude that this is a promising and simple means of potentially improving outcomes for people who elect to undergo on-pump CABG, and that since this is an increasingly challenging population, often with multiple comorbidities, clearly deserving of further study.  They do offer the caveat that propofol should not be used as an anesthetic agent since it appears to abrogate the benefits of ischemic preconditioning. Well.

What is the possible mechanism whereby ischemia induced in the arm would benefit damage to the heart muscle during bypass surgery? For the nerds among us, it turns out that the technique was pioneered in 1986 in dogs by Murray et al, where the observation of a cardioprotective effect with regard to infarct size was made in dogs subjected to ischemia prior to occlusion of a coronary artery.  The exact mechanism(s) are still not understood.  I'd still like to know who made the original observation, since as Rick opines, they're looking pretty smart right now.

Other topics this week include insoles for knee osteoarthritis in JAMA, the low risk ankle rule in the Canadian Medical Association Journal, and overcoming one's genetic risk for diabetes with diet in Diabetes Care .  Until next week, y'all live well.

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Here at Johns Hopkins, the annual flu vaccination season is about to be undertaken.  It is hospital policy that those who have contact with patients must receive an annual flu vaccine, but the pushback in some circles is ferocious.  Even in this bastion of cutting edge medical and scientific endeavor, numbers of people submit that they can't or won't get a flu vaccine.  While some arguments such as egg allergy are persuasive (although may soon be obsolete as flu vaccines will be raised using different techniques) others are more suspect, such as 'I got the flu from the vaccine.'  Impossible, btw.  Okay, rant recorded.  What does this have to do with PodMed this week?  Rick and I discuss a study in Heart, a BMJ journal, showing that among folks at risk for a heart attack or 'acute myocardial infarction,' or AMI, having a flu vaccine halved their risk of such an event.  Yet one more reason to receive the vaccine, methinks.

Australian researchers recruited patients during three winter periods, when exposure to influenza circulating in the population at large was likely. 275 of these folks had an MI and were admitted to the hospital, while 284 were outpatient controls. About half of each group had received the influenza vaccine prior to study enrollment. Subjects were assessed for influenza infection, either laboratory-confirmed or self-report.  Flu infection was found in 12.4% of folks who had had an MI and in 6.7% of controls.  Unrecognized previous influenza infection was found in about 10% of study participants, conferring a two-fold increase in risk among those participants who were hospitalized for MI.  Hmmmm.  If you were told you could cut your risk of having a heart attack in half by having a flu shot, would that be compelling?

Certainly many criticisms could be leveled at this study, but lots of evidence points to the role of inflammation in precipitating cardiac events.  Observational studies clearly demonstrate more MI during flu season, as well as secondary to other causes of inflammation such as air pollution.  Inflammation is known to exacerbate conditions leading to heart attacks such as atherosclerosis.  The authors interpret their study as evidence that vaccination guidelines in Australia should be expanded to include those younger than 65, who currently do not enjoy that status, but here in the US the Centers for Disease Control and Prevention has expanded their recommendations for flu vaccination to everyone over the age of 6 months. It's worth remembering that influenza infection often typically is more severe and can be life-threatening in those at the extremes of age, pregnant women and people with chronic medical conditions but certain flu strains, most notably the one that caused the 1918 flu pandemic, disproportionately killed young and middle-aged adults, whose robust immune response seems to have been the culprit.  Thus it is the most protective for all of us if all of us get immunized.

Other topics this week include IV iron administration and infection in the BMJ , chronic kidney disease in blacks versus whites in JAMA, and the success of a comprehensive approach to blood pressure control in JAMA.  Until next week, y'all live well.

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It's really the stuff of sci-fi, our ability to map the brain so very precisely, and allow for the most targeted of interventions in this sacrosanct space.  Now comes an uplifting study in NEJM Rick and I discuss on PodMed this week, using these amazing high tech gizmos to benefit people with the most common movement disorder, essential tremor.  Yay! I say. Having known people with disabling tremor, and borne witness to their struggle to accomplish basic, ordinary movements, this is good news indeed.

The study was a pilot of 'focused ultrasound thalatomy' in 15 patients who ranged in age from 53 to 79, with severe essential tremor refractory to medication.  Most of the patients were male, right-handed, and had a family history of essential tremor. By necessity, of course, the trial was open label, and all of the participants had failed at least two trials of a full dose therapeutic medication as well as satisfying other entry criteria on degree of tremor and disability.

Treatment consisted of affixing a stereotactic head frame to the patient's shaved head, attaching an elastic diaphragm to the scalp and connecting it to the ultrasound transducer, and filling the diaphragm with chilled water.  The patient was then transferred to an MRI-guided focused ultrasound system, where the area to be treated was mapped and variable numbers of ultrasound pulses employed to ablate specific areas of the thalamus.  While treatment progressed patients communicated with investigators, were asked to draw a series of spirals and tremor suppression was monitored.  Treatment ceased when tremor suppression was observed, then subjects were observed in the neurological intensive care unit overnight. They were discharged the next day.

In the first year after treatment, the mean score for disability dropped by a mean of 85%. Participants also improved in self-rated quality of life and in their score for a simulated eating task.  Four of the study subjects who were unable to complete the task at all prior to the intervention were subsequently able to do so within normal time limits.  Pretty impressive, methinks.

Adverse effects of treatment included transient paresthesias of the face or fingers, and unsteadiness. Four patients were categorized as ataxic at week one but this resolved by week four. One persistent loss of sensation in the dominant index finger was seen. In comparison to other methods for ablating parts of the thalamus, including radiofrequency thalatomy, stereotactic radiosurgery and deep brain stimulation, these have all been associated with a range of adverse events, sometimes occurring quite some time after the intervention, including intracranial hemorrhage and neurological impairment.  This study did not assess possible cognitive impairment but the other adverse consequences of treatment were not seen.  The authors suggest that additional larger, blinded studies are appropriate including an assessment of cognitive function, but these early results are quite encouraging, and Rick and I agree.  What a great utilization of technology with few apparent downsides!

Other topics this week include early heart valve replacement for mitral valve prolapse in JAMA, who benefits from cardiac resynchronization therapy in the same issue, and finasteride for prostate cancer prevention in NEJM.  Until next week, y'all live well.

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When was the last time you actually read a food label?  Not just the nutritional content label, but the list of ingredients?  It's a bit daunting to do so, even if you have abundant experience in chemistry and may really know what some of those things are.  What's become clear over the years is that some of additives in foods are not the best things to consume from a health standpoint; I'm thinking red dye #2, implicated in cancer and banned by the FDA in the late 1970s.  Today, however, you can't count on the FDA to have much say over what's in your food, as Rick and I reveal on PodMed this week, but you know who you can count on?  The manufacturers of said food, as described in a JAMA Internal Medicine study we discuss.   And it's my belief that's a lot like turning the fox loose in the henhouse.

Food manufacturers are empowered by the FDA to determine whether food additives fall into a category known as 'generally recognized as safe' or GRAS. Although the makers are not required to provide the agency with notification of a GRAS determination sometimes they voluntarily do so.  The authors of this study utilized Institute of Medicine criteria on conflict of interest to analyze 451 GRAS notifications provided to the FDA between 1997 and 2012.

The majority of GRAS determinations were made by an expert panel selected by a consulting firm or the manufacturer themselves (64.3%).  Almost a quarter of the determinations (22.4%) were made by an employee of the manufacturing firm (!) and the remainder by an employee of a consulting firm selected by the manufacturer.  Yikes.  Seems like a situation ripe for conflict of interest to me.

A 2011 review cited in this paper states that over 10,000 additives are currently allowed in foods, of which 43% have had a GRAS determination.  The federal Government Accounting Office (GAO) looked  at this issue of GRAS determinations in 2010 and concluded that the FDA should increase its oversight, citing a need for reducing the potential for conflicts of interest and also calling for substantiation of GRAS determinations to the FDA.

Disturbingly, this paper found that when IOM criteria were applied, ALL determinations of GRAS were suspect.  The problem is somewhat academic, of course, because no specific circumstances of food additives that were determined as GRAS by a manufacturer have been subsequently shown to be harmful, and as I point out in the podcast, food makers are not fond of lawsuits and are therefore vested in at least the appearance of safety and concern for public health.  Even so, the opinion of the authors and one with which Rick and I concur is that objective measures should be developed and employed so that the potential for conflict of interest is essentially eliminated, and if that takes a mandate for more oversight by the FDA, okay.  Let's provide them with the resources and let them do the regulation.

Other topics this week include the burden of peripheral arterial disease (PAD) worldwide in the Lancet, glucose levels and dementia in NEJM, and self monitoring of blood pressure in Annals of Internal Medicine.  Until next week, y'all live well.

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Who is responsible for out-of-control healthcare costs and who needs to step up to the plate to fix them?  That's the gist of a recent survey of almost 4000 US physicians, of whom 2556 responded, with the results published in the Journal of the American Medical Association. Their responses are both informative and interesting, Rick and I agree on PodMed this week, and the authors hope that the results will help policy makers and healthcare reform types understand where doctors are coming from when new initiatives are undertaken.

Regarding who has 'major responsibility' for controlling healthcare costs, 60% of physicians said trial lawyers, followed closely by health insurance companies at 59%, hospitals and health systems at 56%, along with pharmaceutical and device manufacturers at the same percentage, and finally to round out the greater than 50% responsibility group, patients themselves at 52%.  Most interestingly, only 36% of responding physicians fingered physicians themselves as having major responsibility for controlling healthcare costs, a fact Rick and I both found fascinating.  I contrast this in the podcast with a recent Johns Hopkins study showing that when physicians are apprised of the true cost of tests they order, they voluntarily order fewer of them or seek less expensive alternatives: http://www.hopkinsmedicine.org/news/media/releases/comparison_shopping_by_doctors_saves_money

"Promoting continuity of care," was rated very enthusiastically by the majority of physicians queried (75%) as one means of reducing costs.  Both expanding access to quality and safety data as well as limiting access to expensive treatments with little net benefit were also enthusiastically embraced by greater than 50% of respondents.

Are physicians aware of the cost of tests and procedures they order?  Just over three-quarters of respondents said they are, with almost 80% saying that physicians should adhere to clinical practice guidelines when deciding which tests or procedures to order.  Rick is gratified to note that 78% embraced the notion that they should act first with the patient's best interest at heart, even if that proved expensive.  Yet almost 90% said physicians need to take a more prominent role in limiting the use of unnecessary tests! Seems a bit contrary to me, but there it is.

Should we change how physicians get paid in order to get ahead of costs?  That notion was extremely unpopular, with only 7% expressing enthusiasm for eliminating fee for service payments. Respondents were also not supportive of cost-containment strategies that bundled quality measures with reimbursement, but were supportive of stand-alone measures to improve quality such as chronic disease management.

So what's the take home?  Clearly, physicians who participated in this survey seem all too willing to cast blame and responsibility on others for soaring healthcare costs, are ready to embrace some changes to rein it in as long as they don't impinge on either income or ability to order tests one deems appropriate.  Hmmm.  As with so many aspects of American medicine, this is a moving target and we'll see what the future brings.

Other topics this week include the even more addictive power of menthol cigarettes, according to the FDA, the benefits of frequent debridement of wounds in JAMA Dermatology, and the role of screening echocardiography in JAMA Internal Medicine.  Until next week, y'all live well.

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The very disparaging term 'doc in a box,' is popular to describe what Rick calls "retail clinics," or RCs, in this week's PodMed, and the danger of utilizing RCs to provide medical care to children, based on a study in JAMA Pediatrics. These clinics, as most people know, often are found inside a retail establishment such as Target or a pharmacy such as Walgreen's.  They're often staffed by nurse practitioners, physician assistants, or sometimes registered nurses, and they provide rapid assessment and testing for a limited range of very common medical complaints as well as ongoing management for conditions such as high blood pressure or type 2 diabetes.  As I confide in the podcast, I've sought their services for a routine pre-athletics physical for one daughter with an unremarkable medical history, when her own pediatrician advised a six week wait for such an assessment!

Researchers surveyed almost 1500 parents who utilized 19 pediatrics practices in the Midwest, asking them about their experience with RCs.  The instrument was a self-administered paper questionnaire which took about five minutes to complete.  Both parents who had and had not visited an RC for medical care for their child were asked to participate.  Those parents who had not utilized such a clinic were asked why not, while those who did were asked about their most recent visit.  Parents were asked about the reason for the visit, how they had learned about the RC they chose, and why they had not gone to their child's usual provider on this occasion. Additional questions regarding the day of the visit, the time of day, how care was paid for and how long the wait to see the provider lasted were also queried. Data was gathered on what the diagnosis was and what care was prescribed, especially antibiotic prescription.

Findings of the study were mostly not surprising: parents who used RCs for themselves were more likely to take their children there, were older and more likely to have more than one child than parents who did not.  Reasons for choosing an RC included convenient hours among almost 40% of respondents, even though almost half of visits to RCs took place between 8am and 4pm on weekdays.  Parents also cited the unavailability of an appointment as a reason.  Most visits were for URIs, ear infections or colds and flu, and very concerning, 85.2% of children with an ear infection, 78.6% of those with a sore throat, and 67.7% of those with a cold or flu were prescribed antibiotics, even when tests did not reveal a bacterial infection.  And along with that concern, many parents reported they did not subsequently inform their child's pediatrician of the visit.

Rick and I both agree that this is potentially problematic, especially with regard to continuity of care.  Since RCs are privately owned they are unlikely to generate an electronic record to the pediatrician's office, so a complete health history will not be available and could have deleterious consequences for the health of a child.  Rick concludes that physicians need to take note of this study and begin asking about RC visits routinely as well as modify office practices to better serve patients.

Other topics this week include maternal smoking and child behavior in JAMA Psychiatry, rabies transmission from a solid organ transplant and breast cancer survival in white versus black women, both in JAMA.  Until next week, y'all live well.

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