Watchful Waiting

July 20th, 2012|Medical News Commentary|By

Most men with localized prostate cancer can be safely watched rather than undergo treatment right away, the PIVOT study reported in the New England Journal of Medicine demonstrates.  Wow!  I quip to Rick in PodMed this week; does this mean the FINAL word on watchful waiting, a.k.a 'expectant management,' or even 'active surveillance' or just simply 'observation' is in?  As Rick so aptly points out, I may be feeling a bit tired of the topic because I lack a prostate gland, but even so, this controversy has raged long enough and a lot of evidence has accumulated.  So what about this latest study?

Researchers recruited 731 men, mean age 67 years, mean PSA 7.8 ng/ml, with localized prostate cancer, to either radical prostatectomy or observation, then followed them for a mean of 10 years.  Outcomes included all cause mortality and prostate cancer mortality.  With regard to prostate cancer mortality, 21 of the men assigned to radical prostatectomy died during follow-up, while 31 men assigned to observation died of their disease.  The researchers calculate the absolute risk reduction of dying from prostate cancer among those treated with radical prostatectomy as 2.6%.

What about all-cause mortality? During the follow-up period, 171 of the 364 men assigned to radical prostatectomy died, and 183 of 367 men assigned to observation did so.  Treatment therefore has little effect on either all-cause or prostate cancer specific mortality, and also did not seem to be impacted by race, age, co-existing medical conditions or histologic features of the tumor.  Well.  What then is the role of radical prostatectomy?

The authors state that in men with PSA values above 10 ng/ml, or those with intermediate or high-risk tumors, the operation may be indicated.  Hmmm, I say to Rick.  When we talk about ongoing controversy PSA as a reliable indicator of much remains a hot topic, as does Gleason score as a way of evaluating prostate tissue.  What factors should propel men into choosing surgery?

Many physicians, including Rick, say that each man's decision must take his own personal factors into account when making a decision to treat or watch.  Factors to consider include not just the PSA level and the Gleason score, but ethnicity, family history, comorbidities, remaining expected years of life, risk tolerance, and perhaps others. The risks of  treatment must also be weighed: in this study just over 21% of men who were treated with radical prostatectomy experienced an adverse outcome within 30 days of surgery, including one death.  Previous research has established that the prospect of urinary incontinence and sexual dysfunction dissuade many men from surgery, with especially poignant retrospective studies establishing their regret at choosing surgery when such outcomes were experienced.

Admittedly, it's easy for me to reach the conclusion that if I had localized prostate cancer I would elect active surveillance since that won't ever happen in my lifetime.  Reiterating 'active surveillance' is germane, though, since the clear goal is to keep checking it to make sure things are okay.  For now, I would say to almost any man who's looking at ads for robotic prostate surgery, caveat emptor.  Pay attention, consider very carefully, and perhaps just wait and see.

Other topics this week include egg allergy treatment in NEJM, the dangers of eating disorders in Pediatrics, and in Annals of Internal Medicine, reducing trans fats in fast food.  Until next week, y'all live well.

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Fido Is A Kid’s Best Friend

July 13th, 2012|Medical News Commentary|By

If you're expecting a child should you be shopping for a dog alongside your crib and other baby paraphernalia?  That's one conclusion of a study in this week's Pediatrics, looking at the number of upper respiratory infections, or URIs, for the cognoscenti, among infants in their first year of life, living in homes that also owned dogs or cats, or both.  As Rick and I quip in PodMed, maybe that's good reason to visit an animal shelter and recycle a life while protecting your child.

This study was undertaken by those inventive Finnish, whose ability to gather socially conscious subjects into studies such as this one is the envy of public health proponents everywhere.  Investigators began following almost 400 children in utero, during the third trimester of pregnancy.  All the study children were born between September 2002 and May 2005.

Extensive data collection was accomplished with weekly diary questionnaires parents kept from the ninth postnatal week, asking questions about infectious symptoms, healthcare attendance, and dog and cat exposure. More data was gathered on those children identified as unwell by parents, including the presence of fever, cough, rash, wheezing, middle ear infection, or urinary tract infection.

Pet exposure was broken down into categories based on how much time the dog or cat spent inside the house. Breastfeeding either completely, partially, or not at all was also noted, as well as other data on parental allergies, education level, siblings, and the season of the subject's birth.

The study found that both dog and cat contact in early life appeared to result in a greater number of healthy weeks and fewer URIs among infants exposed to these pets in the home compared to those without such exposure.  Dogs appeared to confer more protection than cats.  These infants also had fewer episodes of otitis media, or middle ear infections.

Interestingly, the middle ground of dog exposure appeared best, that is, the dog was outside some of the time rather than in the house all the time.  The authors speculate that these dogs may bring more dirt inside with them, thus exposing the nascent immune system to a range of bacteria and other organisms that may help it become more competent in fighting off the bad guys, such as rhinoviruses.  Rick and I note a study we discussed in a podcast some years ago showing that children reared on farms experienced less allergy and asthma than their city-dwelling counterparts.  Perhaps similar mechanisms are at work here, helping the individual develop a library of friend and foe from an immune response perspective.

In any case, Rick advocates for visiting a shelter and at least procuring a dog for your nieces or nephews, while my concern is the impact such an action may have on your relationship with your brothers or sisters.  While considering pet ownership for yourself or others, you may want to sip cranberry juice to prevent urinary tract infections, according to a study in Archives of Internal Medicine.  And you may want to add vodka to that, according to a study in the British Medical Journal showing that women who consume moderate alcohol develop fewer cases of rheumatoid arthritis.  And finally, HIV infection can be curtailed in some at-risk populations, three studies in the New England Journal of Medicine find.  Until next week, y'all live well.

 

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July 6th, 2012|Medical News Commentary|By

Has your primary care physician commented on your weight?  If he or she is like many colleagues in medicine, the answer is no. (And according to at least one recent study, if he or she is overweight they're even less likely to mention weight as an issue). That may change now that the United States Preventive Services Task Force, also known by the acronym I stumble over in this week's PodMed, USPSTF, has issued recommendations regarding screening and management of obesity in adults.  That's an online first publication in Annals of Internal Medicine. 

First a little background for those who haven't looked at the latest obesity figures (no pun intended) in the United States:  The paper states that since 1976 to 1980, the prevalence of obesity and overweight in the United States have increased by 134% and 48%, respectively. In 2007 to 2008, 40% of men and 28% of women in the United States were overweight and 32% of men and 36% of women were obese. The prevalence of obesity exceeds 30% in most age- and sex-specific groups, with approximately 1 in 20 Americans having a BMI greater than 40.  Yowl!!

We don't have to look very far to discern the many negative consequences of overweight and obesity, including increased risk of diabetes, some types of cancer, which the task force identifies as liver, kidney, breast, prostate, endometrial and colon, but could well include other types, and heart disease.  The USPSTF also mentions that obesity confers an increased risk of osteoarthritis, respiratory and gall bladder disease, as well as disability.

Many great minds have been hard at work trying to figure out how to stem this tide of obesity.  Perhaps enrolling primary care physicians in the act will have an impact.  First, physicians should use BMI to determine whether a patient is overweight or obese, although waist circumference may also be employed, the task force recommends. When a patient is determined to be overweight or obese, patients should be referred to high intensity, comprehensive interventions.  And here's the rub:  turns out that while many physicians may state that weight control is needed, few actually refer their patients for intervention.  

What does such an approach entail? Multifactorial strategies including individual or group counseling sessions, occurring 12-26 sessions in the first year, setting weight loss goals, improving nutrition, increasing physical activity, addressing barriers to change, active use of self-monitoring, and strategizing on how to maintain lifestyle choices are all identified by the USPSTF guidelines.  Whew!  Clearly, referral is required as no primary care physician could keep on top of all of that, but it sounds like it could keep the patient very busy, too. 

What about the role of medications?  Maybe, a lukewarm task force seems to say, citing evidence that both orlistat and metformin can assist behavioral interventions to lose weight but the former sometimes associated with liver disease and the latter used off-label in the application.  No mention of the latest FDA approved weight loss agent, lorcaserin, but that's just been approved, so no surprise there.

In summary, physicians must encourage their patients to lose weight when appropriate, and should emphasize the fact that even modest weight loss will result in improvements in blood sugar and perhaps other conditions such as pain due to osteoarthritis or breathing problems.  Hmmm.  Let's see if this helps.

Other topics this week include, in the same issue of Annals, a look at 'lifelong learning' requirements for physicians, aka: CME, and a lack of efficacy with healthy lifestyle counseling.  In a journal we have never reported on before, a look at osteoporosis screening and management guidelines in men.  That's in the Journal of Clinical Endocrinology and Metabolism.  Until next week, y'all live well.

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Thyroid Nodules and What They Mean

June 29th, 2012|Medical News Commentary|By

Lots of people develop dense collections of tissue in their thyroid gland as they age, known as nodules.  In fact, estimates of the prevalence of thyroid nodules range from up to 8% of women and 2% of men with palpable nodules to almost one-third of women when ultrasound is used for screening. Given the abundant use of imaging methodologies such as CT, more and more of these so-called 'incidentalomas' are found  and therefore require follow-up, and there's the rub,  Rick and I agree in PodMed this week. Lots of unnecessary evaluation and treatment, otherwise known in the parlance as overdiagnosis and overtreatment, ensue.  Help may have arrived with a study in NEJM making use of a genetic technique to assess thyroid nodules and perhaps avoid unnecessary surgery.

Almost 4000 patients and almost 5000 fine needle aspiration biopsies of thyroid nodules were included in this study.  All the aspirates came from nodules 1cm or more in size that required further evaluation.  Of these, almost 600 were of indeterminate cytology, which happens in 15-30% of cases,  so 265 were tested using a gene expression classifier.

85 of the aspirates tested using the gene expression classifier turned out to be malignant, with 78 of the 85 correctly identified by this system, giving a 92% sensitivity and a 52% specificity.  Negative predictive values ranged from 85 to 95% for "atypia (or follicular lesion) of undetermined clinical significance,” “follicular neoplasm or lesion suspicious for follicular neoplasm,” or “suspicious cytologic findings.” 

All of the samples used in this analysis were correlated with examination of tissue removed at thyroidectomy.  The authors conclude that this gene expression classifier could be used to recommend watchful waiting rather than thyroidectomy for many patients.  While surgical outcomes following thyroid gland removal are usually good, 2-10% of patients who've undergone thyroidectomy report long term morbidity.   Clearly, lifelong thyroid hormone replacement is needed and may need adjustment.

The test is good news for the up to 30% of people whose fine needle aspirations of thyroid nodules don't point in a clear direction and would otherwise result in surgery, eliminating both unnecessary expense and risk.  Other topics this week include the development of sprue or celiac disease with use of a common blood pressure medication in the Mayo Clinic Proceedings, liver complications due to a medical food in Annals of Internal Medicine, and use of tissue plasminogen activator or TPA in folks already taking the blood thinner coumidin, in JAMA .  Until next week, y'all live well.

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Alcoholism and Obesity Surgery

June 22nd, 2012|Medical News Commentary|By

If you have surgery to help you combat obesity, are you putting yourself at risk for alcoholism?  That's one potential sobering conclusion (no pun intended) from a study in this week's Journal of the American Medical Association. Rick and I agree in PodMed, though, that the risk presented by the surgery relative to development of alcoholism pales in comparison to the many health risks associated with or known to be caused by obesity.

The study gathered data from almost 2500 people who underwent some type of obesity or bariatric surgery, most commonly the Roux-en-y type of operation but a lesser number with the lap band, where a device is placed via laparoscopy around the stomach to reduce its capacity.  The median body mass index of study participants preoperatively was almost 46, median age 47 years, and almost 80% female. 

All participants were screened prior to surgery using the Alcohol Use Disorders Identification Test, a 10 item questionnaire designed and validated to assess alcohol use and consequences in the previous 12 months.   Another questionnaire was used to assess perceived social support on the part of patients, and use of recreational drugs, smoking and binge eating disorders were also queried. 

Postoperative follow up occurred at one and two years.  This analysis includes data from 1945 participants, and shows that alcohol use disorder or AUD symptoms did not differ from one year before to one year after bariatric surgery (7.6 vs. 7.3%), but then increased in the second postoperative year to 9.6%.  Factors associated with a greater risk of AUD included male gender, younger age, smoking, regular alcohol consumption, AUD prior to surgery, recreational drug use, and lower interpersonal support.  Risk for developing AUD was also seen when Roux-en-Y surgery was employed rather than the lap band.

Why would bariatric surgery be associated with an increased risk for AUD to begin with?  The authors state that there is some evidence that Roux-en-Y surgery and an increasingly popular form of bariatric surgery known as gastric sleeve that was not included in this study, alter the metabolism of alcohol, such that people who consume a standard amount of alcohol reach a higher peak level sooner after surgery than before, and that more time is required to return to sobriety postoperatively compared to preoperatively.  Rick and I agree that such observations require further study to substantiate them.

Should concerns about alcohol use disorders elicit caution regarding the selection of suitable candidates for bariatric surgery?  As stated at the outset, most unlikely.  Cancer, heart disease, diabetes, arthritis...the list of very likely and potentially life-threatening complications of obesity is extensive, and those who need such intervention probably would list concerns about alcohol use disorders as low indeed.  Should healthcare professionals be more vigilant in asking about alcohol use after surgery, and especially in long term follow-up?  That's probably the most practical strategy at this point.

Other topics this week include better cardiovascular risk blood markers, also in JAMA, is chronic kidney disease an equivalent for heart attacks in the Lancet, and the 6 minute walk test in Archives of Internal Medicine.  Until next week, y'all live well.

Why migh

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Blood Clots and Hormonal Contraceptives

June 18th, 2012|Medical News Commentary|By

Hormonal contraceptives are among the most effective means of preventing pregnancy currently in use.  As time goes on, the list of contraceptives with a hormonal mechanism of action gets longer:  oral contraceptive pills of various formulations, vaginal rings, transdermal patches, depot injections, hormone releasing intrauterine devices, implants...seems like the list is limited only by the imagination of drug manufacturers to develop the sine qua non of contraceptives, embodying convenience, effectiveness, acceptable cost and side effect profile, and reversibility.  Yet one troubling aspect of hormonal contraceptive use remains- the risk of blood clots.  Now a study in the New England Journal of Medicine looks at the risk of clots forming in arteries rather than the more typical clot in a vein, so-called venous thrombosis.  Reassuringly, as Rick and I discuss in PodMed, that risk is very small.

The study originated in Denmark, analyzing data from over 1.6 million women, with over 14 million person years of observation, from January 1995 through December 2009.  The women were 15 to 49 years of age during the 15 year study period.  Data on smoking status was available for almost half a million of these women.

Not surprisingly, as women aged they were more at risk for both thrombosis or cardiac problems.  Those women at the higher end of the education spectrum were less likely to experience either thrombosis or a cardiac event. Those women who used hormonal contraceptive products that relied only on progestin did not experience any increased risk, while those who used combination products saw a modestly increased risk of thrombotic events.

Here's what the data revealed:  the researchers state that "among 10,000 women who use desogestrel with ethinyl estradiol at a dose of 20 μg for 1 year, 2 will have arterial thrombosis and 6.8 women taking the same product will have venous thrombosis. Although venous thrombosis is three to four times as frequent as arterial thrombosis among young women, the latter is associated with higher mortality and more serious consequences for the survivors. Therefore, these figures should be taken into account when prescribing hormonal contraception."  As I point out to Rick in the podcast, these numbers sound inflammatory when taken as a percentage increase but are really quite small when absolute risk is assessed.

Moreover, I would balance these risks against those experienced during pregnancy, childbirth, or abortion.  Clearly, this study demonstrates that the risk of hormonal contraception is not zero, and women should probably have their blood pressure assessed accurately previous to using such methods, shouldn't smoke, should take their family history into account, and should probably choose another contraceptive method as they age to reduce these modest risks.

Other topics this week include use of fish oil or insulin in people at cardiovascular risk and diabetes or prediabetes, also in NEJM, exercise testing after revascularization in the long term, and statins and fatigue, both in Archives of Internal Medicine.  Until next week, y'all live well.

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Hedgehog Inhibition

June 8th, 2012|Medical News Commentary|By

PodMed starts out this week with Rick quipping, "what does stopping hedgehogs have to do with curing cancer?"  Turns out the most common type of skin cancer- basal cell carcinoma- may have finally met its match with a drug that inhibits a pathway known as 'hedgehog,' two studies in the New England Journal of Medicine demonstrate. 

The drug is known by the awkward name of 'vismodegib,' and it was used in two different patient populations: those who had locally advanced or metastatic disease, and folks with basal cell nevus syndrome, where they develop hundreds or even thousands of basal cell carcinomas during their lifetime.  At best, people with this syndrome must undergo repeated surgical procedures, resulting in scarring and discomfort.   Those with locally advanced or metastatic disease face death from basal cell carcinoma.

The study looking at locally advanced and metastatic disease enrolled 33 patients with metastatic disease and 63 patients with locally advanced disease.  Both groups received 150mg of oral vismodegib daily.  The response rate among those with metastatic disease was 30%, while 43% of those with locally advanced disease responded.  The study on basal cell nevus syndrome treated 41 patients, who received the same dose of vismodegib as the previous study, planned for 18 months or until intolerable side effects developed. This interim analysis revealed that the drug reduced both the number of basal cell nevi in the treated group compared with the placebo group, and reduced the size of the lesions.

Great news, right?  Yes, but side effects were common in both studies.  In the study on those with basal cell nevus syndrome, over 50% discontinued the drug due to side effects, including muscle cramps, hair loss, taste disturbance, weight loss and fatigue.  In the study on those with locally advanced or metastatic disease, 7 deaths due to adverse drug reactions were noted.  Seems like targeting this pathway is a great idea but further drug development to refine the target and reduce such side effects is clearly desirable.

As I opine in the YouTube this week, maybe we should all take a lesson from this pathway's namesake, 'hedgehog,' and become nocturnal, as is the animal.  Failing that, a very large number of these basal cell cancers could be avoided by avoidance behavior: staying out of the sun, using hats and clothing to cover up, and use of sunscreen.  Regular all body skin examination could also catch them early, before locally advanced or metastatic disease develops.  In this case we do know that early treatment is likely to be successful.  For those unfortunate folks with basal cell nevus syndrome, seems that for now, regular check ups and excisions remains the best strategy, and we know additional hedgehog inhibitors will be developed, hopefully with a more benign side effect profile.

Other topics this week include two studies on the disturbing rise in multidrug resistant tuberculosis and a new agent for treating it in NEJM, screening for intimate partner violence in Annals of Internal Medicine, and the bleeding risk associated with aspirin for primary prevention of heart disease in JAMA.  Until next week, y'all live well.

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Picking up Chicks

June 1st, 2012|Medical News Commentary|By

Picking up chicks may be bad for your health.  That's Rick's quip in this week's PodMed and my intro for the YouTube.  We're both talking not about sexually transmitted infections or other risks of what many of us likely conjure up when we think 'picking up chicks,' rather, we're talking about live young poultry and the risk of salmonella infection, as reported in this week's New England Journal of Medicine.

Yes, indeed, turns out that a very lengthy and exhaustive sleuthing process described in this study identified mail order poultry as the cause of an outbreak of Salmonella Montevideo taking place in the United States between 2004 and 2011.  During this time period there were 316 cases in 43 states, with cases peaking in the spring.  About a quarter of those who developed the infection were hospitalized, but no deaths were reported.

The mean age of those who developed salmonella infection was 4 years.  When investigators asked caregivers of these children whether they were aware that salmonella infection could be acquired through contact with an infected bird, only 21% of those interviewed said yes.  Only 7% reported that when they purchased the bird they were informed, either in writing or orally, about the risk of salmonella infection from the animal.

So outside of the wow value of the impressive investigation necessary to identify the hatchery the infected birds came from, what are the public health implications of such a study?  Turns out that standards for reducing the likelihood of salmonella infection relative to live birds shipped elsewhere are not the same as those for commercial hen or egg production, and are also voluntary.  As the study authors point out, this investigation also reveals the difficulties inherent in trying to effectively interrupt salmonella infection in poultry.

So while we're waiting for some law-level interventions, what's a responsible parent or consumer to do?  Obviously, one effective intervention is simply NOT to order chicks for Easter, which likely is why at least some of these birds were purchased.  A look at the picture of dyed chicks, above, clearly demonstrates their almost irresistible cuteness, but like puppies, they do grow up and need to be taken care of.  Can't overcome desire?  A few hygiene measures can be employed:  keep the birds out of the house and don't keep them near food or places where food is prepared.  WASH YOUR HANDS (btw, the single most important infection control measure you can perform anywhere, anytime) after handling the chicks, and don't allow your young children to handle them at all.  Having had young children, I would say it's a very good reason not to even buy the birds in the first place.

Older people and those with compromised immune systems are also at risk for acquring this infection, and may additionally experience more dire consequences, so once again, avoidance is prudent. It's worth keeping in mind that the birds infected with salmonella do not themselves appear sick, so that's no metric for reducing infection risk.

Other topics this week include a look at hormone replacement therapy guidelines in Annals of Internal Medicine, and three studies in Archives of Internal Medicine: the cardiovascular impact of both hypo- and hyperthyroid, and intensive glucose control and kidney disease.  Until next week, y'all live well.

 

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The Last Word on PSA Testing?

May 25th, 2012|Medical News Commentary|By

Prostate specific antigen or PSA testing has been a mainstay of prostate cancer screening for some time now, and the subject of a LOT of controversy for the last several years.  That's because what has become abundantly clear is PSA screening identifies many, many cancers that may never cause a problem, giving rise to the idea that most men left to their own devices will die with, rather than from, prostate cancer.  BUT once found, treating prostate cancer gives rise to a host of unwanted side effects, including urinary incontinence and erectile dysfunction.  In fact, one study Rick and I talked about a year or so ago on PodMed surveyed men who had undergone treatment for prostate cancer who subsequently said they wouldn't have done so if they had known how troublesome these side effects would be for them.  Hmmmmm.  So now the United States Preventive Services Task Force or USPSTF, has stepped into the fray with a set of guidelines basically saying to men, just say no, as I quip in the YouTube, PSA screening is more trouble than it's worth. The guidelines are published in the current issue of Annals of Internal Medicine, and conclude, succinctly, that "The USPSTF recommends against PSA-based screening for prostate cancer (grade D recommendation)." 

Well.  Game, set, match? Here's some background:  the last time the USPSTF took a look at this issue in 2008, they decided the evidence was inconclusive.  Now they've crunched some pretty sobering numbers, such as the fact that almost 16% of men will be diagnosed with prostate cancer at some point in their lifetime, with a lifetime risk of dying from prostate cancer of about 3%.  The recommendations cite the terms 'overdiagnosis' and 'pseudo-disease' to describe the fact that a) PSA screening results in the detection of many prostate cancers that are asymptomatic, and b) a substantial number of those detected will not progress or will do so so slowly they would never cause a problem.

So how many men have really benefited from PSA screening?  The guidelines estimate the number as very small indeed, since it would include only those men who underwent screening, had a cancer that was detected and treated, and survived.  Their best guess on this number is 1 in 1000.

The flip side to this, of course, is what about false-positive results, consequences of treatment, and the development of the aforementioned conditions that are problematic at best for men once their prostate cancer has been treated?  That number looms large as in the hundreds per 1000 men treated. Check out the paper itself via the hyperlink, above, for the table.

So what's a man to do?  Seems pretty clear to me that unless one is part of a high risk group, perhaps having a family history of prostate cancer or being of African American descent, giving this test a miss sounds persuasive.  Rick confides that he hasn't and has no intention of having PSA screening.  I do think though that it's going to be some time before practices are penetrated and adopt the new guidelines, and in the meantime, we'll still be hearing more about this.

Other topics this week include the dangers of calcium supplements in Heart, a British Medical Journal, the benefits of flexible sigmoidoscopy in NEJM, and diabetic foot ulcer treatment in Clinical Infectious Diseases.  Until next week, y'all live well.

 

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Coffee Drinkers Rejoice!

May 21st, 2012|Medical News Commentary|By

Coffee has been a subject of intense interest for medical researchers for some time, with all sorts of studies aimed at assessing whether coffee ingestion increases or decreases one's risk for any number of conditions or diseases, including but not limited to cancer, high cholesterol, dementia, and death.  As I opine in this week's PodMed, seems like those of us who love coffee can finally rejoice and imbibe yet one more cup of Joe, based on a study in the New England Journal of Medicine.

This study used data from the NIH-AARP Diet and Health Study, a very large questionnaire-based sampling of AARP members aged 50 to 71 years.  The survey asked questions about 124 dietary items, including consumption of red and white meats, saturated fats, fruits and vegetables, alcohol and coffee,  and a host of lifestyle factors such as exercise and smoking. Health status and a number of diseases and conditions impacting health status was also queried. For this analysis data from almost 230,000 men and over 173,000 women were included.

Coffee consumption was pinned down more precisely with 10 frequency categories, ranging from 0 to six or more cups per day. That would be an 8 ounce cup, btw, so those among us who are trying to compare our own habits must take into account the size of our typical cup.  Over 95% of respondents provided information on whether they drank caffeinated or decaffeinated coffee (mostly caffeinated), and also what type of coffee they used regularly: 79% drank ground coffee, 19% instant coffee, 1% espresso coffee, and 1% did not specify the type of coffee they consumed. 

Interesting but not surprising associations were found along with coffee consumption:  more cigarette smoking, more than three alcoholic drinks per day, more red meat consumption.  And less exercise, less education, lower consumption of fruits and vegetables.

Death and causes of death were also recorded for this cohort.  The numbers were crunched for all-cause and cause-specific mortality in association with coffee consumption and factoring out confounders like cigarette smoking.  The study concludes that male coffee drinkers who imbibed 6 or more cups of coffee per day experienced a 10% lower risk of death.  Women who consumed six or more cups of coffee per day had a 15% lower risk of death.  Now, it must be admitted that this is not a huge benefit, certainly not what is realized by smoking cessation, regular exercise, or careful attention to diet, but not insignificant.  And as Rick and I quip, since we're both regular exercisers, don't smoke, aren't overweight and don't eat a bunch of bad stuff, and do drink coffee, we're going to live forever!

 Limitations of this study are cited by the authors and we agree:  observational studies are rife with possibilities for skewed data, and self-report questionnaires notorious for their unreliability.  I did confide to Rick, however, that when a prospective study on coffee drinkers comes to the fore, I'm glad to volunteer as a subject.  At the moment it's enough to know that I can keep up my addiction with a clear conscience.

Other topics this week include whether stress testing ought to be done in people who've had procedures to restore blood flow to their hearts in Archives of Internal Medicine, a laxative-free colonoscopy in Annals of Internal Medicine, and how air pollution impacts inflammation in JAMA.  Until next week, y'all live well.

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