iStock_000049397454_MediumCan we somehow identify people when they have their first episode of mental illness, surround them with a comprehensive array of therapies and support, and stave off development of frank schizophrenia?  Yes, a study published in the American Journal of Psychiatry and that Rick and I discuss this week on PodMed concludes.  Here's what they did: the study was called 'NAVIGATE,' and the approach utilized community-based care with four components: personalized medication management, family education about mental illness, individual therapy and employment or education.  Just over 400 people were randomized to either this intervention or to usual care.  They were followed for a minimum of two years.

Here's what they found: "The 223 recipients of NAVIGATE remained in treatment longer, experienced greater improvement in quality of life and psychopathology, and experienced greater involvement in work and school compared with 181 participants in community care."  Rick opines that while up front costs of this approach are undoubtedly higher than usual care, the long term benefits and likely reduction in costs relative to society would more than compensate for embracing this approach.  Here's a fact both of us found startling: "The median duration of untreated psychosis was 74 weeks. "  Wow. These folks were out there for over a year on average with untreated psychosis! Given the knowledge that early interventions work better, seems like the clear conclusion is to identify and enroll people as soon as possible.

Other topics this week include nicotinamide and skin cancers and outcomes of total knee replacement or not in NEJM, and use of medicines to manage cardiovascular risk worldwide in the Lancet.  Until next week, y'all live well.

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iStock_000049191016_MediumAs if Ebola virus infection wasn't nightmare enough in the acute phase, more information is coming out about long term presence of the virus in two studies from NEJM Rick and I discuss on PodMed this week. It's worth mentioning that in the New York Times is also a report regarding sequela of infection in a nurse. Add to that previous tales of sequelae in survivors and the picture is bleak indeed.  Okay, what does NEJM show?

The first article documented sexual transmission of Ebola virus infection from a presumed recovered man to a woman, who subsequently died.  He was infected in September of 2014 and had unprotected sex with the woman in March of 2015. Molecular analysis of the virus showed it was the same between the couple. The second study looks at persistence of Ebola virus in the semen of 100 convalescent men and here are the results: "Ebola virus RNA was detected in the semen of all 9 men who had a specimen obtained 2 to 3 months after the onset of EVD (Ebola virus disease), in the semen of 26 of 40 (65%) who had a specimen obtained 4 to 6 months after onset, and in the semen of 11 of 43 (26%) who had a specimen obtained 7 to 9 months after onset..." Frightening indeed, although the infection potential is unknown.  Clearly these studies coupled with other reports bring us to the inescapable conclusion that there's an awful lot we still don't know about this virus, with ongoing surveillance and research remaining a priority.

Other topics this week include cancer in elephants in JAMA, carbapenam resistant enterobacteriaceae in JAMA, and red wine, type 2 diabetes and cardiovascular risk factors in Annals of Internal Medicine.  Until next week,y'all live well.

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iStock_000040985910_MediumIf you're an older person who's taking beta blockers, a popular medicine for managing high blood pressure, and you're about to have surgery, you now have one more thing to think about before the procedure: should you stop taking this medicine?  A study Rick and I discuss on PodMed this week, as featured in JAMA Internal Medicine, suggests the answer may be yes, as after correcting for a large number of potential confounders and rigorously case-matching, an increased risk was seen for those taking beta blockers and having non-cardiac surgery.

The study looked at almost 15,000 patients who were taking beta blockers at the time of noncardiac surgery compared to almost 41,000 taking other high blood pressure medicines at the time of surgery. Major adverse cardiovascular events, including cardiovascular death, nonfatal ischemic stroke, or nonfatal myocardial infarction, and all-cause mortality, occurred almost twice as often among those taking beta blockers compared to those on other medicines for the same indication. Risk was greater for males, those older than 70, and for those undergoing acute procedures rather than elective ones. Will cessation of this medication ameliorate risk?  Not known from this data, but definitely a topic for presurgery discussion with your provider.

Other topics this week include ischemic preconditioning and heart surgery in NEJM, bioprosthetic valve problems in the same journal, and risk of hospitalization for community acquired pneumonia in those vaccinated for flu in JAMA.  Until next week, y'all live well.

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iStock_000000382250_MediumGood news for anyone who's trying to stop smoking as well as all the rest of us who abhor the habit:  turns out smoking low nicotine, and I do mean low, cigarettes results in people cutting back or stopping without really trying, a study Rick and I discuss on PodMed this week as published in NEJM demonstrates.  And high time, we agree, for the FDA to begin regulating the nicotine content of cigarettes, as it is empowered to do and now has persuasive data to support such an action.

A total of 780 people who smoked at least five cigarettes per day and had no intention of quitting were enrolled in this six-week randomized trial. They were assigned to their usual brand or a cigarette containing 15.8 mg per gram of tobacco, the usual dose, or  to cigarettes containing 2.4, 1.3, or 0.4 mg of nicotine per gram of tobacco.  At the end of six weeks, those smokers in the low nicotine groups were smoking significantly fewer cigarettes than those in the control or usual brand groups, and some had made attempts to quit altogether.  Symptoms of withdrawal did not vary substantially among groups nor did any adverse events.  In short, the low nicotine cigarettes seem like good tools to enable smokers to move toward quitting without much downside.

Other topics this week, also in NEJM, include a look at cardiometabolic risk factors in obese children, and treatment of cancer during pregnancy with regard to outcomes for the child, and in the BMJ, an exhaustive meta-analysis once again concluding that for the majority, calcium supplementation should be abandoned.  Until next week, y'all live well.

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iStock_000050124278_MediumIf you have had a teenage child who's depressed, or even been around one who is, you know that such a state often creates panic on the part of parents, since impulsivity and adolescence also commonly sort together and the threat of self-harm seems present.  How egregious then, as Rick and I report on PodMed this week, that a mega pharmaceutical company should manipulate its data to purport a benefit to the common antidepressant paroxetine for the treatment of depression in this age group.  And kudos to the folks at RIAT, that's 'restoring invisible and abandoned trials,' for reanalyzing the data and publishing this paper in the BMJ.  Now we just need to get the word out to anyone who prescribes antidepressants to teenagers to abandon use of paroxetine.  Here's what happened:  in 2001 SmithKline Beecham published study 329, purporting positive results and an acceptable safety profile for this drug in adolescents. Now that the data has been crunched again, not only isn't there a benefit, significant harm with respect to suicidal ideation is seen.  The good news is the FDA has stepped in and fined the company a rather large amount, and we hope that acts as a deterrent to pharma to cease such practices in the future. We also support the RIAT initiative, which is calling for public access to primary data from all trials.

Other topics this week include a new drug for reducing death among those with type 2 diabetes in NEJM, taking blood pressure medicines at bedtime in Diabetologia, and the relationship between atrial fibrillation and dementia in JAMA Neurology.  Until next week, y'all live well.

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iStock_000055627278_Medium (1)Hip replacement surgery is something that seems likely for many, if not most, as they age. Now comes a study Rick and I discuss on PodMed this week looking at outcomes following said surgery when the procedure was elective versus when it followed a fracture, in JAMA.  Turns out that when matched for everything, including age, gender, multiple co-existing medical conditions, and whether the procedure was scheduled or post-traumatic, those who underwent surgery in the post-traumatic state were six times more likely to die before hospital discharge than those who had elective surgery. That's quite a difference, and one that seems robust given that this study looked at data accumulated from over 300,000 patients over a three year period. Folks who had the surgery secondary to a fracture were also three times more likely to develop complications.

How do we account for this dramatic difference? Rick speculates that some inflammatory condition secondary to trauma might be the culprit, while the authors of the study also speculate that performing surgery as quickly as possible following the fracture might help mitigate some of the pro-inflammatory response.  We all agree that additional research is needed to pinpoint the cause of the increased risk so attempts can be made to minimize it.  Other topics this week include aspirin recommendations for cardiovascular risk reduction and colorectal cancer risk reduction from the USPSTF, long term follow-up of diabetes prevention in the Lancet, and in the same journal risk of death among children of atomic bomb survivors.  Until next week, y'all live well.

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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.

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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.

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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.

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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.

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