If you're at risk to develop diabetes, and in these days of increasing body mass and sedentary lifestyle, who isn't? perhaps you'd prefer a switch to what's morphed into a 'Mediterranean diet,' from your normal pattern of consumption rather than hiring a former Marine as a personal trainer or going on a prolonged juice fast. That's one interpretation of a study Rick and I discuss on PodMed this week, published in Annals of Internal Medicine.  And as we quip, we'd be happy to ship out to the Mediterranean to consume same as we're enduring some rather frigid weather right now on the east coast of the US, but what do investigators do in this study?

The study enrolled over 3500 men and women at risk for the development of cardiovascular disease in Spain, with this particular study representing a subgroup analysis.  The study took place from October 2003 to December 2010, with an average follow up of 4.1 years. Participants were randomly assigned to one of three dietary groups: a Mediterranean diet supplemented with extra-virgin olive oil (EVOO), the same diet supplemented by nuts, and a control group who simply received dietary advice on low-fat consumption. Study subjects were also stratified with regard to age, sex, and study site. No weight loss or physical activity interventions were employed. It should be noted that the Mediterranean diet is actually fairly high in fat consumption, with about 35-40% of calories from fat, largely vegetable in origin. Dairy products are limited, and moderate alcohol consumption, particularly red wine, is typical.  Tomato-based sauces and garlic figure prominently.

One of my favorite aspects of the trial was that subjects were provided with either EVOO, nuts, including hazelnuts, walnuts and almonds, or nonfood items associated with shopping or cooking, depending on which group they were assigned to.  Wow!  Anyone who's taken a look at the price of EVOO lately might consider that supplement a powerful inducement to entering and completing the study.  All subjects met with a dietician and competed diet questionnaires at 3 month intervals. Among the many assessments performed at study enrollment was the absence of diabetes.

During the follow up period, 273 participants developed diabetes, 80 of whom were in the EVOO dietary group, 92 in the nut supplementation group, and 101 in the low-fat advice group.  Crunching the numbers leads to the conclusion that the Mediterranean diet groups experienced an overall 30% reduction in their risk of developing diabetes over the study period compared with the control group, with the group consuming the EVOO faring best.  There was no weight loss seen in any group, which as I comment to Rick in the podcast, calls into question the idea that increased BMI alone is the culprit when it comes to the rampant development of type 2 diabetes worldwide.  Clearly this is also good news for folks who aren't willing to endure Draconian measures to either lose weight or increasing physical activity, but are willing to make chances to their diet.  As we opine, however, results are no carte blanche with regard to increasing BMI, as it remains associated with many other health issues including cardiovascular disease, osteoarthritis and cancer.

Other topics this week include a novel device for overcoming obstructive sleep apnea in NEJM, and an entire issue of which we highlight two studies on cigarette smoking in JAMA.  Until next week, y'all live well.

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Those of us at a certain age , including Rick and me, recall the 1990s craze for vitamin E.  At the time studies concluded that vitamin E supplements could stave off dementia, and every neurologist I knew was downing the capsules in the fervent hope that the horror of developing dementia would be avoided.  Then came a slew of studies that attempted to utilize the vitamin for cancer and cardiovascular disease prevention.  Not only did these studies turn out to be disappointing, some of them actually indicated that vitamin E might increase the risk for certain conditions, notably prostate cancer. Just like every other vitamin, mineral, trace element or supplement craze before it, this one too dropped off the map.  Now, as we discuss on PodMed this week, it's bacccckkkkkkk.  JAMA reports a study where folks with established dementia were randomized to high dose vitamin E alone, in combination with memantine, memantine alone, or placebo.  Guess what?  Those who took the vitamin E alone slowed down the progression of their condition by six months.

The study population was culled from 14 Veteran's Administration medical centers, so it was largely male. All 613 participants who enrolled in the study in had mild to moderate Alzheimer's disease and were followed for 6 months to 4 years. At enrollment they were randomized to 2000 IU of alpha-tocopherol per day, 20 mg of memantine daily, the combination, or placebo. The primary outcome measure was the  Alzheimer’s Disease Cooperative Study/Activities of Daily Living (ADCS-ADL) Inventory score, but other cognitive, functional and neuropsychiatric measures were also employed, as was an assessment of caregiver involvement.

Besides the delay in progression of symptoms of dementia, the need for increased caregiver involvement was also lowest in the group receiving vitamin E alone.  There was no benefit to memantine either alone or in combination, although the memantine receiving groups did have an increased risk of "infections or infestations(!)" No deleterious side effects from vitamin E were noted.

Well, what do we make of this?  Constantine Lyketsos, an Alzheimer's disease expert at Johns Hopkins, says he is persuaded by this study and will suggest vitamin E supplements to his patients with mild to moderate AD.  The caveat of course is that he will only recommend this intervention in those with mild to moderate disease.  This study, and the studies before it, do not establish a benefit for those in earlier stages of dementia, nor do they even intimate a role for vitamin E with regard to prevention.  What seems clear from this study as well as emerging data from many others is that there is a course of progression of AD where one intervention may be helpful but isn't at another point, and that seems to be the case with many other disease states as well. So for all of us who believe we're not demented yet, and really don't want to be, vitamin E supplementation isn't the ticket.  Sigh.

Other topics this week include driving distractions and car mishaps in NEJM, mammography statistics in JAMA Internal Medicine, and the global effects of smoking, also in NEJM.  Until next week, y'all live well.

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Are you familiar with your meniscus? Or menisci, to be more precise?  The term most often refers to the two pieces of cartilage sandwiched between the femur and the tibia inside your knee joint, and for some they are troublesome indeed. That's because they are prone to tear, either traumatically or as a result of wear and tear, and the usual method for dealing with that is to arthroscopically clean up the frayed parts, often in conjunction with or following other types of management such as steroid injections, physical therapy, and weight loss. Now comes a study published in the New England Journal of Medicine that Rick and I discuss on PodMed this week showing no benefit to surgery.  As I rather sarcastically remark to Rick, surprise!

The study took place in Finland, where such studies can be undertaken because there's less threat of litigation, in a modest 146 patients. All of the subjects were between 35 and 65 years of age, had no evidence of osteoarthritis in the knee joint, but did have symptoms consistent with a tear in the medical meniscus, and who did not respond over three months duration to conservative conventional treatment. MRI was performed on all participants to confirm the presence of a tear; final confirmation was performed at arthroscopy.  At arthroscopy, patients were randomized to either partial meniscectomy or elaborate sham surgery, completely simulating the meniscectomy without actually removing tissue.  Patients were blinded to their assignment, as were all providers outside of the surgeon and OR staff.

Study subjects were followed for 12 months with a primary outcome measure of knee pain and a couple of other measures, including quality of life.  Here's what the authors write, "Although marked improvement from baseline to 12 months was seen in the three primary outcomes in both study groups, there were no significant between-group differences in the change from baseline to 12 months in any of these measures." Well.  Guess that sums it up nicely, and fits well with much of the data from numerous studies demonstrating clearly that surgical interventions for a variety of conditions are not superior to time in pain reduction or improving function.  The caveat must be emphasized however, that all subjects in this study underwent a graded exercise program following their procedure and this no doubt improved function and stabilization of the knee joint.

A few statistics are worth repeating here:  partial arthroscopic meniscectomy is the most common orthopedic procedure performed in the United States, with an annual outlay of direct medical costs of approximately $4 billion dollars.  In this era of cost containment the procedure is clearly worth scrutinizing for efficacy.  As with so many conditions people develop, prevention is also worth a close look: would more regular physical activity and weight control reduce the number of folks who would develop this condition to begin with? For now, Rick and I agree, it's worth advocating for the 'tincture of time.'

Other topics this week include eating nuts during pregnancy in JAMA Pediatrics, BRCA screening recommendations in Annals of Internal Medicine, and dietary supplements and liver disease, in the New York Times.  Until next week, y'all live well.

 

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What makes a soap 'antibacterial' and are there any benefits conferred by such a product that are underpinned by evidence?  Moreover, are the ingredients of such a product more of a health risk than the bugs they supposedly dispatch?  Those are just a few of the questions the FDA is pondering regarding soaps marketed to consumers as 'antibacterial,' and as Rick and I discuss on PodMed this week, precipitated our first foray into discussing something not based on a study and completely lacking evidence.  Hmmm. New trend, anyone?

Here's the story:  this week the FDA announced a proposed rule that will require manufacturers to provide data that demonstrate both safety and efficacy in reducing harmful bacteria with products labeled as antibacterial.  Right now there is no evidence at all that such products are superior to plain old soap and water in reducing bacterial load or specific harmful species.  Moreover, the ingredients contained in these soaps and body washes available over the counter include triclosan and triclocarban, two chemicals that may have harmful effects on people, especially when they are used long-term.  Triclosan has been shown in animal studies to alter hormonal regulation and may also promote the development of antibiotic resistant bacterial species. Triclocarban is also suspected of affecting the action of testosterone.  Right now, both of these ingredients can be found in a range of consumer-directed products, including clothing, kitchenware, furniture, cosmetics and toothpaste, in addition to body washes and soaps.  Thus the range of exposures could be vast and the time period prolonged.

What specifically is the FDA proposing to do?  A new standard for laboratory testing that directly tests the ability of a product to reduce infection rates will be employed.  The agency is also working with the EPA to gather and integrate research data relative to triclosan with regard to risks related to exposure, especially as they occur over time. The FDA is also encouraging consumers and anyone else with an interest in this issue, including clinicians and scientists, to weigh in during the comment period for the new rule, which extends for 180 days. Okay, what about the rest of the madding crowd?

Rick suggests that for now, consumers read the labels of products they buy or have on hand around the house and see if triclosan or triclocarban are among the ingredients, and then make a decision about whether the risks of exposure are acceptable.  Certainly there seems to be no acute, immediate risk but if long term risks are a personal concern, dispose of the product.  The FDA and Rick and I all advocate for the pronounced ability of handwashing to reduce infection and contamination risk, however, so replacing your antibacterial product is encouraged if it keeps you washing your hands.   For anyone who reads the labels of produces used in hospitals or healthcare facilities, it's important to note that the proposed rule does not apply to products designed to be used in these settings.

Other topics this week include panning multivitamins in Annals of Internal Medicine, new recommendations for defining and managing high blood pressure from the 8th Joint National Committee, and calcium channels blockers and clarithromycin and acute kidney injury in JAMA.  A very Merry Christmas to all, and y'all live well.

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I love to see the new words that are added each year to the Oxford English Dictionary.  For example, this year 'selfie' made the cut. For Stedman's, 'overdiagnosis' is surely about to be added, since as Rick and I discuss on PodMed this week, we're seeing that term applied to more and more cancer screening modalities.  Interesting also that the timeline for applying this term has become truncated; raising the specter of overdiagnosis with regard to prostate cancer took some several years.  This week, JAMA Internal Medicine has published an analysis of the National Lung Screening Trial, hailed just a couple of short years ago as a major advance in detecting early lung cancers among those at risk for the disease by employing spiral CT, but now reinterpreting the data to demonstrate the likelihood of falsely fingering lung cancers that may not have ever caused a problem.  Huh?

As a reminder, the National Lung Screening Trial employed either low-dose CT scanning or routine X-ray to annually screen almost 54,000 people with a 30-pack year history of cigarette smoking over a period of three years, with up to five years of additional follow-up.  The upshot of the first foray through the data revealed that low dose spiral CT was superior to routine X-ray in detecting lung tumors and on that basis, was inserted as the screening modality of choice for those at high risk of lung cancer.

This data spin calculates several additional numbers:  excess cancers detected, both from a clinical and a public health perspective using different denominators, for different types of lung cancers, and the number of overdiagnoses relative to the number needed to screen to prevent one lung cancer death.  The researchers determined that there's an 18.5% probability that any lung cancer detected by low dose CT represented an overdiagnosis, and that with regard to certain types of lung tumors that probability was almost 23% for non-small cell lung cancer and a whopping 78.9% when the cancer was bronchoalveolar!  If we accept the calculation that 320 people would need to be screened to prevent one lung cancer death in this population, then 1.38 cases of overdiagnosis would occur in this group as well.

So what does this mean for people who are at high risk for developing lung cancer? Rick opines that these folks should still undergo screening, but if they are told they have a suspicious lesion or frank tumor, they should seek an opinion and treatment from someone with abundant experience in this area.  Lung biopsies of course are not without risk and overtreatment can carry considerable risks.  The authors as well as Rick and me are hopeful that better imaging techniques, biomarkers and a host of other initiatives will bear fruit and provide us with a better method of figuring out who can be safely left alone. And of course I wouldn't be me if I didn't call for simply abolishing cigarettes as the most effective strategy.

Other topics this week include a lack of benefit seen with genetic analysis in assisting with Coumadin dosing in NEJM, diabetes and hypoglycemia risk in JAMA Internal Medicine, and lipid management in chronic kidney disease in Annals of Internal Medicine.  Until next week, y'all live well.

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As we've experienced a huge global upswing in the number of people who are overweight and obese, studies of these folks have been undertaken with regard to health risk relative to BMI. One recent meta-analysis including almost 3 million subjects paradoxically demonstrated that those who fell into the category of overweight, with a BMI of 25 to 30, enjoyed longer life that those who were obese (BMI greater than 30) or those of normal or underweight.  The argument was advanced that people with increased BMI but who were metabolically healthy  were in fine shape with regard to longevity.  Now, as Rick and I discuss on PodMed this week, another meta-analysis published in Annals of Internal Medicine concludes that that's false: people who are overweight and obese die earlier than their leaner counterparts.  Let's look at what these investigators did.

Observational studies of the effect of metabolic status in normal weight, overweight and obese people with regard to cardiovascular events and all-cause mortality and the clinical characteristics of what the authors call 'metabolic-BMI phenotypes' were included in this analysis.  Over 61,000 individuals were represented and almost 4000 events. There were six categories of subject: metabolically healthy and normal weight, metabolically healthy and overweight, metabolically healthy and obese, metabolically unhealthy and normal weight, metabolically unhealthy and overweight, and metabolically unhealthy and obese. The metabolically unhealthy categorization was based on the presence of metabolic syndrome components as defined by a couple of organizations, and included the usual suspects such as triglyceride, LDL and HDL levels, use of blood pressure lowering medications, waist circumference and the like.  Two studies also looked at insulin resistance and inflammatory markers as part of the metabolic assessment.

The study found that when studies of at least 10 years of follow-up were analyzed separately, obese subjects did indeed experience a greater risk of all-cause mortality and cardiovascular events in comparison to the normal weight group.  At all levels of weight the metabolically unhealthy subjects were about three times more likely to experience an event or die that those who were metabolically healthy.  The authors interpret this to mean that some evaluation of metabolic health should be included in any comprehensive assessment, and that studies must be undertaken for sufficient periods of time to discern differences in outcome.

Rick makes the point in the podcast that the increased mortality risk seen with obesity may be a long term risk, but many short term risks are also seen with increasing body weight, including knee osteoarthritis and back problems, among others. We conclude that busting the myth that fatness may be overcome by fitness is important in supporting weight control goals along with exercise targets for all.

Other topics this week include the chickenpox and shingles vaccines and their impact on adults and treating anemia in heart disease patients, also in Annals, and treating ischemia in folks with coronary artery disease in JAMA Internal Medicine.  Until next week, y'all live well.

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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