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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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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