iStock_000037757998_MediumTelemedicine is booming, expanding from the evaluation of people with movement disorders to those in far-flung locales without access to psychiatrists, and now, with apps on smartphones capable of capturing vital signs and transmitting them easily, to primary care.  Hot off the press, as Rick and I discuss on PodMed this week, the American College of Physicians has published recommendations in Annals of Internal Medicine to guide this expansion.  While there are few surprises here, my take on the situation is the more such bodies get on board and establish a position, the more rationally the thing can proceed, which we both predict it certainly will.

Things that are noteworthy in the guidelines include the primary directive that telemedicine services should be extended only to patients with whom the physician already has a relationship.  Hmmmm. Even in the primary care setting it seems to me that some people face a multitude of challenges in turning up at a physician's office, and some provision for that should be made.  Other recs include the need to develop reimbursement schedules for this service as well as credentialing and licensing across the country, as docs will likely be providing services to folks in other states.  Rick and I agree that as the electronic health record becomes more robust, expansion of telemedicine will take place alongside, so establishing a position relative to primary care is a good benchmark.  Other topics this week include a real world trial of pre-exposure prophylaxis in those at risk of HIV infection in the Lancet, a look at who's transmitting pertussis to infants in Pediatrics, and the rate of revision for sling placements to treat urinary incontinence in women in JAMA Surgery. Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_000055153054_Medium1-120x86If you were asked if a surgeon made more mistakes if he or she had had an interrupted night's sleep the evening before a procedure, you might agree with Rick, as he opines on PodMed this week, and say yes. The question is an old one, and one that has been studied largely in interns and residents.  Now comes a study in NEJM taking a look at the same surgeon performing elective procedures, both after an interrupted night's sleep previously or not.  Pretty good control, huh?  And Rick was surprised by the outcome: with regard to endpoints including death, readmission, complications, length of stay, and the duration of the procedure, guess what?  NO difference.  That's right, these outcomes were virtually the same regardless of sleep interruption.  I wasn't particularly surprised, and that may be because experienced surgeons performing elective procedures become expert at doing so, are likely to have a team in place to support them, and have had to get their game on multiple times previously.  Still, we agree that this is going to be an ongoing issue for study, and outcomes may be different for emergent or unfamiliar procedures or under a host of other scenarios.  Good news, though, for folks who have elective procedures.

Other topics this week include Chagas' cardiomyopathy, also in NEJM, susceptibility to cold virus infection with shortened sleep duration in Sleep, and management of chronic sinusitis in JAMA.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_000070441973_MediumFlibanserin is the rather tongue-twisting name of a medication that has just been approved for 'hyposexuality' in women.  As such, it has garnered enormous attention from many on both sides of the fence, with rather few in the middle, Rick and I discuss on PodMed this week.  We're reporting from an FDA press release.

First of all, what is hyposexuality?  The expanded term is actually 'generalized hypoactive sexual desire disorder,' abbreviated HSDD.  It occurs in premenopausal women and is unrelated to other medical or psychiatric conditions, problems with a medication or drugs, or relative to relationship issues, and causes significant distress and/or interpersonal difficulty.  Okay, that's a mouthful.  And the beat goes on.  The abstract version of this story is that flibanserin improves this condition only modestly in those who respond to it, and may have a number of side effects while doing so.  As such, women are recommended to attempt using flibanserin for a relatively short period of time and if improvements aren't noted, discontinue it.  Providers must become certified in its use and pharmacies that dispense it must also.  Seems like a lot of barriers to me!  On the flip side, proponents point out that there is currently no medication for this condition so it is defensible to approve it.  In contrast to many things we discuss on the podcast, Rick and I really don't take a hard and fast position on this one.  No doubt that will change as the drug is used by more women.

Other topics this week include USPSTF recommendations on screening for COPD, a polypill for congestive heart failure in NEJM, and an analysis of cancer risk and alcohol consumption in the BMJ.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_000048350132_MediumAre e-cigarettes the greatest thing since sliced bread or a machination of the devil?  The rancorous debate roils on, with studies abounding, as Rick and I discuss on PodMed this week.  Now comes a study in JAMA that seems to supports the latter assertion, at least for teenagers.  The study followed just over 2500 9th grade students from several California high schools, all of whom reported never having used a combustible tobacco product (note new terminology, cognoscenti) at the time of recruitment. The students were assessed at baseline, at six months, and then at 12 months of follow-up for e-cigarette and combustible cigarette use. In summary, those who reported e-cigarette use were more likely than those who didn't use the devices to begin combustible tobacco product use over the year of follow-up.  The finding suggests that e-cigarettes are a means to addict people to nicotine use and promote a transition to frank smoking.  As Rick opines in the podcast, this is troubling because teenagers are a vulnerable population, with developing brains that are susceptible to nicotine as well as other psychoactive substances.  We agree that regulation of e-cigarettes as well as traditional cigarettes should include prohibition of sales and use in those younger than 21 years of age.

Other topics this week include a genetic basis for different types of fat in our bodies, with implications for obesity in NEJM, the impact of being part of a military family on children, and liraglutide for managing weight in people with type 2 diabetes in JAMA.  Until next week,y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_000012783948_MediumButter lovers, rejoice!  A study Rick and I discuss on PodMed this week and as published in the British Medical Journal once again comes to the conclusion that when it comes to cardiovascular risk relative to the development of atherosclerosis, saturated fats are not the culprit, but that human invention, trans fats, are. In point of fact this meta-analysis went further than that, assessing 12 studies with regard to all cause mortality, cardiovascular disease mortality, coronary heart disease, ischemic stroke, type 2 diabetes and consumption of saturated and trans fats.  Yikes.  That's a lot of data parsing! In short, the study concludes that consumption of saturated fats was not associated with any of the outcomes identified above, but consumption of trans fats were associated with all cause mortality and coronary heart disease morbidity and mortality.

Trans fats, as I suggest in the podcast, were developed for a number of reasons, among them the idea that saturated fats were involved in the deposition of plaques within arteries known as atherosclerosis.  But surprise!  Turns out when we mess with nature and produce chemical bonds in places they don't normally occur, so called 'trans fats', these are actually worse from an atherosclerotic viewpoint.  So leave that margarine alone, I say, and enjoy your butter, chocolate, nuts and other sources of saturated fat, but don't go overboard.  The majority of what you consume should still be vegetables and fruits, in a form as close to nature as possible.  And don't forget the postprandial walk.

Other topics this week include cardiac troponin significance in people with diabetes in NEJM, fresh versus frozen oocytes in JAMA, and testosterone supplements and atherosclerosis in men, in JAMA.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 5.0/5 (1 vote cast)
2 Comments

iStock_000046130062_MediumAt long last, a vaccine has been developed and tested that provides virtually total protection from Ebola virus infection, a great news study published in the Lancet has shown. Yay! Rick and I rejoice on PodMed this week.  Seems like it's been a long time coming, with thousands of people dying in rather horrific ways.

The study used a " open-label, cluster-randomised ring vaccination trial" design, with almost 8000 subjects from among people presumed to be exposed to someone with frank, confirmed Ebola virus infection. Briefly, some of the contacts were vaccinated immediately after their presumed exposure while others were vaccinated 21 days later. Development of Ebola virus disease in immediate and delayed vaccination groups was assessed, revealing 100% efficacy for the vaccine in preventing disease in those vaccinated immediately. Next steps will of course expand vaccination efforts and hopefully Ebola will be simply a blip on the landscape until the next viral illness emerges.  Other topics this week include restoring Circadian rhythm in persons who are totally blind with an eye toward alleviating insomnia, also in the Lancet, in Lancet Oncology a reduction in endometrial cancer risk with oral contraceptives, and management of anticoagulation in people with atrial fibrillation who may need stents, in the JACC.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_000023037295_LargeKids are famous for putting things in their bodily orifices that subsequently require a visit to an ED to assess and remove.  Especially lately, batteries of the button variety seem to be in vogue.  Enter now, as Rick and I discuss on PodMed this week, an actual therapy involving placing a balloon in the nose of a child (!) as a treatment for fluid accumulation in the middle ear following an ear infection, or in the vernacular, middle ear effusion after acute otitis media.  The study is reported in the Canadian Medical Association Journal, and I'm guessing it's just a matter of time before this is the latest on the playground.  And just in time for back to school!

A total of 320 children aged 4-11 who had acute ear infections and effusion were randomized to the nasal balloon three times daily or usual care for a period of three months (!).  The children were amazingly compliant with treatment; at one month 89% were using the balloon as prescribed, and at three months 80% were doing so.  The strategy also resulted in about 12% greater likelihood of resolution of the effusion at both one and three months.  Sounds like a win-win to us.  Other topics this week include depression screening recommendations from the USPSTF, hypothermia for kidney graft donors, and a new treatment for elevated triglycerides, both in NEJM. Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

HiResThe profound impact of poverty on children has been chronicled in lots of studies, but this week Rick and I discuss on PodMed a study that looks at specific brain areas in kids raised in poverty and those raised without that barrier.  As published in JAMA Pediatrics, the sobering revelation is that in brain areas associated with learning readiness, including the frontal lobe, temporal lobe, and hippocampus, reduced gray matter was seen in those raised in poverty.

Brain composition was assessed using MRI scans from 301 participants in the NIH Magnetic Resonance Imaging Study of Normal Brain Development study. One-quarter of sample households reported their total family income below 200% of the federal poverty level, with the remainder spread across the income spectrum.  Educational attainment of parents was also assessed in this study, and perhaps most distressingly, at least for me, college and even graduate degrees of their parents offered no protection with regard to poverty or brain development for those children at the bottom of the income scale.  As I speculate with Rick in the podcast, seems like it should be fairly straightforward to find the smoking gun(s) and develop interventions to overcome this problem.  In our world of abundance, saddling children with such a disability at the very beginning of life is indefensible.

Other topics this week include the interaction of Coumadin with dicloxacillin in JAMA, bystander CPR (2) in the same journal, and likelihood of overcoming obesity in the American Journal of Public Health.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_000012753279_FullCould one benefit of aging be taking fewer medications?  That outrageous idea may be the upshot of a study Rick and I discuss on PodMed this week, as published in JAMA, taking a look at appropriate management of high blood pressure in those aged 80 and older. The study aggregated six post hoc analyses of data from the Hypertension in the Very Elderly Trial, conducted in almost 4000 hypertensive subjects over the age of 80. The analysis concludes that for older folks who are generally healthy and functional, high blood pressure should be managed according to the guidelines for those older than 65, with positive impact on outcome measures such as total mortality and cardiovascular events.  A target systolic blood pressure of 140-150 should be employed, and one or two medications at most, relieving many of the burden of polypharmacy, or at least reducing it. For those who are frail, and already taking a multitude of medications for other conditions, hypertension management should be conservative at best, with that catch all phrase 'individualized treatment' used.

No doubt for many older folks, this relaxation of blood pressure targets will come as a relief, and underscores observations we've made before: as we age our physiology changes, and reasonable accommodation should be made.  Other topics this week include the cost and effectiveness of cholesterol guidelines and a new drug for high potassium, also in JAMA, and in NEJM, a snapshot of community acquired pneumonia.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

iStock_000044730596_Full (1)No one wants to have shots, but they're especially problematic in children.  Welcome then was the news a few years back that a simple tablet placed under the tongue could induce enough tolerance that many children with allergies might forgo allergy shots altogether.  Alas, as Rick and I discuss on PodMed this week, it appears the early results haven't been borne out, at least according to a meta-analysis in JAMA Internal Medicine.

Data was pooled from over 4500 patients in whom sublingual immunotherapy utilizing tablets took place in a randomized controlled trial.  Outcome measures were symptom management and use of medications to control symptoms.  A very modest benefit of sublingual immunotherapy was seen in terms of reduction in symptoms or medication use, while over 60% of study subjects reported adverse events, compared with about 21% of the control population.  Well.  Rather disappointing, as I've already opined, but also calls into question the basis upon which the FDA approved sublingual immunotherapy in 2014.  At the very least calls for re-examination of the issue and perhaps a comparison with standard issue allergy shots.

Other topics this week include extended use of anticoagulation in folks who've had pulmonary embolism without a discernible cause, and continued cognitive decline after stroke, both in JAMA, as well as rates of healthcare workers coming to work while ill, in JAMA Pediatrics.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments