iStock-172476633Teenagers are well-known for their propensity to have car accidents. Now comes a study Rick and I discuss on PodMed this week and published in JAMA Pediatrics that identifies ADHD as a likely big contributor to motor vehicle crashes, raising the issue for both parents and society at large of the need to find out why, and develop strategies to help.

This retrospective study compared a bunch of data relative to teenage driving, including age at which a driver's license was obtained, presence of ADHD, medication use for ADHD, and a police-reported crash, between almost 2500 adolescents with the condition versus almost 16,000 without. Median age of subjects at the end of the analysis was just over 22 years.

The study found that those with ADHD were 36% more likely to have a motor vehicle accident than those without the condition. This did not vary by age, sex, or over time. Somewhat disturbingly, a minority of the study subjects were prescribed medication for ADHD, so attempting to assess whether crash risk is modified by medication use isn't very robust given the numbers. Rick and I agree that this study points out a clear need to find out why teens with ADHD are at increased risk and to develop interventions.

Other topics this week include Glucose Self-monitoring in Non–Insulin-Treated Patients With Type 2 Diabetes in JAMA Internal Medicine, and Association of Adverse Events With Antibiotic Use in Hospitalized Patients in the same journal. From NEJM,Health Effects of Overweight and Obesity in 195 Countries over 25 Years. Until next week, y'all live well.

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043127685-grilled-assorted-vegetables-1-416x625If you were offered 'caramelized, oven-roasted zucchini bites' rather than 'zucchini,' would you be more likely to choose vegetables more often at a cafeteria? Yes, a study Rick and I discuss on PodMed this week and published in JAMA Internal Medicine concludes. Here's what they did: At Stanford University the researchers utilized four different ways to describe vegetable dishes at a university cafeteria that served about 600 diners per weekday lunch. The diners were undergraduate and graduate students mostly and some staff. The four methods used to describe the veggies were "basic, healthy restrictive, healthy positive, or indulgent." There was no difference in how the vegetables were prepared.

This study was conducted over one academic quarter, for a total of 46 days. During that time almost 28,000 meals were served and just about 30% of them included a vegetable. When vegetables were labeled indulgently rather than basically, 25% more people selected them. Indulgent versus healthy restrictive? 41% more. Indulgent versus healthy positive? 35% more.  And people ate 23% more of the indulgently labeled dish. Perhaps Stanford could integrate creative writing with food service and give credit for the most persuasive labeling! In any case sounds like an easy way to increase vegetable consumption.

Other topics this week include Association of Educational Attainment With Lifetime Risk of Cardiovascular DiseaseThe Atherosclerosis Risk in Communities Study, also in JAMA Internal Medicine,  and two from NEJM:Lithium Use in Pregnancy and the Risk of Cardiac Malformations, and Efficacy and Safety of Degludec versus Glargine in Type 2 Diabetes. Until next week, y'all live well.

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86496585Getting involved in your own care may help you live longer if you have cancer, a research letter Rick and I discuss on PodMed this week and published in JAMA shows. The letter reports outcomes from a strategy developed by oncologists at Memorial Sloan Kettering to allow patients to report their own symptoms - so called 'patient reported outcomes' or PROs - and record them into their electronic record. When the patient identified a severe or worsening symptom, an email alert was sent to the nurse who was involved in the person's care, and the nurse was then empowered to make changes to the chemotherapy dose or to supportive medications, provide counseling for symptom management, or make appropriate referrals. Nurses did so 77% of the time they received an alert in this study.

Benefits to patients who reported their symptoms over a median of seven years of follow up included longer median survival: 31.2 months for the PRO group versus 25 months for the usual care group, and longer duration of chemotherapy: 6.3 months in the usual care group versus 8.2 months in the PRO group, which the authors speculate may be the mechanism by which the PRO group survived longer. They also recommend that such a strategy could be integrated broadly into cancer care for almost all, since one in eight of the patients in this study were non-white and almost a quarter had a high school education or less.

Other topics this week include Growth and Rupture Risk of Small Unruptured Intracranial Aneurysms in Annals of Internal Medicine, Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline in the BMJ, and Completion Lymph-Node Dissection in Melanoma in NEJM. Until next week,y'all live well.

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iStock-538904110Keeps the cardiologist away. That's what Rick quips on PodMed this week as we discuss a study in the BMJ on the benefits of consuming chocolate with regard to prevention of atrial fibrillation. How intriguing! This study relied on information from the Danish Diet, Cancer and Health Study, using data from over 55,000 Danish men and women, ages 50-64 years at baseline. These folks have been followed for a median of 13 and a half years, and have had a bunch of data gathered about them at the inception of the study and at follow up.  Food questionnaires were administered and validated against two 7-day weighed diet records, a fact I find most impressive since many criticisms of these types of studies center on recall bias as a primary fault.

During the follow up period, over 3300 cases of atrial fibrillation were identified. This is possible of course because of the Danish registry of citizens, which provides each of them with a unique number by which their interactions with the healthcare system can be tracked. When considered in relation to each other, the study found that those who consumed more chocolate had a reduced incidence of atrial fibrillation. And since atrial fibrillation is common, and associated with a higher risk of stroke, heart failure, cognitive decline and dementia, and mortality, perhaps this in one way to help avoid the condition. Rick says that while the prospective study of the impact of cocoa on cardiovascular outcomes is completed (currently underway) he's just going to keep eating chocolate and recommends that others do the same.  Dark chocolate of course, as is eaten by most Danes.

Other topics this week include Dietary intake of fibre and risk of knee osteoarthritis in two US prospective cohorts and Pharmaceutical-grade chondroitin sulfate is as effective as celecoxib and superior to placebo in symptomatic knee osteoarthritis: the ChONdroitin versus CElecoxib versus Placebo Trial (CONCEPT), both in the BMJ's Annals of Rheumatic Diseases, and in NEJM: Trial of Cannabidiol for Drug-Resistant Seizures in the Dravet Syndrome. Until next week, y'all live well.

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iStock-611776510Does your doctor's age affect whether you will die within 30 days of admission to a hospital? According to a study in the BMJ Rick and I discuss on PodMed this week, the answer is yes, if you're 65 or older. The numbers in this study are huge: over 730,000 Medicare admissions managed by almost 19,000 hospitalists across the country, which represented a 20% sample of such admissions between 2011 and 2014. The basic question was what was the 30-day mortality associated with the age of the physician? Besides hospitalists, the analysis also included data from general internists.

The study found that for physicians younger than 40, the 30 day mortality was 10.8%. For those 40-49, it was 11.1%, 11.3% for the 50-59 age range, and finally, for those 60 years of age or greater, was 12.1%. Older physicians also had slightly higher costs of care, and most interestingly, the difference disappeared when volume was factored in, with those seeing larger numbers of patients having the same rates.

Well. Rick speculates that perhaps there are cultural differences among older physicians, citing his own experience in practice as very much a solo flyer, perhaps without the benefit of team assessments and other support that might influence these figures, such as not accessing the evidence base when making decisions, and suggests strategies for assessing these possibilities. Another physician I know, also in the 60+ cohort, suggests that older physicians, by way of experience, may simply step out of the way when faced with a patient whose outcome looks as if no intervention would be beneficial, while younger physicians may be operating with the adage that 'when there's life there's hope.' Clearly, such a bias could also be assessed in further studies.

Other topics this week include another from the BMJ: Online abortion service is safe and effective way to end pregnancy, finds study, and two from Annals of Internal Medicine: Prevalence of Elevated Cardiovascular Risks in Young AdultsA Cross-sectional Analysis of National Health and Nutrition Examination Surveys, and Missed Opportunities for MMR Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultation. Until next week, y'all live well.

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iStock-624748148Endometriosis is generally considered to be a benign condition, even though it is associated with pelvic pain and sometimes infertility. Now comes a study Rick and I discuss on PodMed this week, as published in NEJM, that seems to suggest that some of these lesions may not be so benign after all, at least as judged by the presence of mutations in DNA taken from them that are associated with cancer. What did they do?

Researchers obtained tissue from 27 patients with what they characterized as 'deeply infiltrative endometriotic lesions.' Lesions from 24 of the patients were analyzed by means of whole exome  sequencing, while 4 were analyzed using cancer-driver targeted sequencing. Results indicated that more than a quarter (26%) carried cancer-driver mutations, and all of these were confined to the epithelial compartment of the lesion.

Well. What is the significance of these mutations given that for most, transformation into frank cancer is unlikely? As Rick and I speculate in the podcast, seems like there's a lot we don't know about so-called cancer mutations and the likelihood that they will actually produce cancer. Clearly simply the presence of the mutation alone is insufficient. Does transformation also require environmental factors or additional mutations? And how will these findings affect efforts to develop early screening tools for cancer? If 26% of people with so-called benign conditions carry these mutations they clearly aren't useful for predicting malignancy. Back to the drawing board, it may be. And as for the 10% of young women who have endometriosis, maybe NOT testing them is prudent since who knows how such information may be used by insurance companies to deny coverage for pre-existing conditions?

Other topics this week include Use of the NHLBI Data Repository, also in NEJM, one from JAMA: Postmarket Safety Events Among Novel Therapeutics Approved by the US Food and Drug Administration Between 2001 and 2010, and in the BMJ: Diet high in vegetables, fruit, and whole grains may reduce risk of gout. Until next week, y'll live well.

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iStock-157614058Scientific jargon can be tedious, and so it is with this new agent Rick and I discuss on PodMed this week, a PCSK9 inhibitor called evolocumab, and long term cardiovascular outcomes, as published in NEJM. As I opine to Rick, I can hardly wait for the proprietary name as the consonants strung together just don't slide easily off the tongue, and based on the results of this study these agents will no doubt be in widespread clinical use soon. What did the study show?

Almost 28,000 people with both atherosclerotic cardiovascular disease and LDL cholesterol of 70 mg/dl or higher and who were already taking statins were randomized to either the monoclonal antibody evolocumab or to placebo. Study participants received the antibody or placebo by subcutaneous injection once every two weeks.  After a median 2.2 years of follow up the primary composite endpoint was cardiovascular death, heart attack, stroke, hospitalization for unstable angina or revascularization. When compared with placebo the PCSK9 inhibitor achieved an almost 60% reduction in LDL cholesterol. Even more importantly, the drug reduced the likelihood of an adverse cardiovascular event significantly. Rick opines that the conclusion seems clear: reducing LDL cholesterol even more than can be achieved with statins alone does reduce the risk of cardiovascular outcomes in those at risk, and believes these agents will soon be used widely, noting that there were no adverse events seen in either arm of the study.

Other topics this week include two more from NEJM: Bystander Efforts in Out-of-Hospital Cardiac Arrest and Tofacitinib for Ulcerative Colitis, and in Annals of Internal Medicine, Handgun Acquisitions in California After Two Mass Shootings. Until next week, y'all live well.

 

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iStock-528438369What can people from the island of Sardinia teach us about the genetics of autoimmune disease and interaction with infectious disease resistance? Wow, that's a bit of a stretch out into serious nerd territory, but this study in NEJM that Rick and I discuss on PodMed this week is an intriguing demonstration of evolution at work, and potentially some other hypotheses. What did they do?

Researchers gathered data from almost 3000 persons with multiple sclerosis (MS), 411 with systemic lupus erythematosus (SLE), and almost 3400 controls from across Sardinia, as well as a population cohort of more than 6900 volunteers from elsewhere on the island. Case control data sets hailed from mainland Italy, the UK, Sweden, and the Iberian peninsula. Genome-wide association testing was undertaken and an area that encodes a cytokine and " drug target B-cell activating factor (BAFF)," was found to be associated with both MS and SLE.  The mechanism appears to be upregulated humoral immunity through increased BAFF levels, B lymphocytes and immunoglobulins. Most interestingly, this variant also seems to be beneficial with regard to malaria resistance, which has been historically endemic on the island. Evolution at work! We also speculate in the podcast on the role of autoimmune disease and lifespan, since Sardinia is home to the world's largest population of centenarians. At the very least it appears that there's no compromise of longevity, though testing those centenarians for the specific variant would be the best proof. For now, identifying and understanding more of the genetics and mechanisms of autoimmune disease works.

Other topics this week include Time to Colonoscopy After Fecal Testing and Colorectal Cancer and USPSTF recommendations on preeclampsia in JAMA, and in Stroke, Beverage Intake, Incident Stroke, and Dementia. Until next week, y'll live well.

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iStock-174295373Have you ever taken corticosteroids? I have, once, following a serious bout of poison ivy, and while at the time I really needed them I might think twice today. Turns out that single, short term use of steroids may cause a host of negative side effects, a new study Rick and I discuss on PodMed this week and published in the British Medical Journal shows. And since the study also shows that over 20% of adults in the US younger than 65 years of age have been given a prescription for oral corticosteroids, that's concerning indeed.

The study took a look at private insurance claims among adults 18-64 years old between 2012-2014. This represented claims by over 1.5 million adults, of whom over 327,000 received a prescription for short term (less than 30 days) use of oral corticosteroids. Most of these folks received their prescription from a multitude of providers for upper respiratory infections, spinal conditions and allergies. More likely to take the meds were older folks, women, and white adults.

When looking at possibly associated negative side effects, the study identified a disturbing and significant increase in sepsis, venous thromboembolism, and fracture among those who took steroids, even a single, short term use. Plausibility exists for these associations since these are the self-same warnings given by the FDA with regard to prescription of these drugs.  Yikes! What can be done? Clearly, monitoring the prescription of steroids more closely and assessing these associations prospectively is needed before panic ensues. Yet for now, carefully assessing prescription of steroids is also prudent.

Other topics this week include Azithromycin and ventricular arrhythmia in CMAJ, Screening for Retinopathy in Type 1 Diabetes in NEJM, and Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis in Annals of Internal Medicine. Until next week, y'all live well.

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iStock-505700149Low back pain is virtually a given for the majority of us, with studies showing that almost everyone will experience an episode, and some will have a recurring or longstanding problem. Now comes hope, as Rick and I discuss on PodMed this week and published in JAMA, in the form of a meta-analysis taking a look at spinal manipulation, or chiropractic, in improving pain.

Participants in these trials who were included in the analysis had acute, lower back pain of less than or equal to 6 weeks duration. Spinal manipulation therapy was able to reduce pain moderately and for up to six weeks, about the same as using a non-steroidal anti-inflammatory medication.  As Rick opines, that's pretty good as it avoids the harms associated with medications. What about the harms of spinal manipulation? The study found that such harms were transient and musculoskeletal in nature. On the detraction side is also the fact that chiropractic costs more than simply popping an OTC medicine. On the whole, however, the evidence tilts the scales in favor of attempting spinal manipulation, with Rick confiding that he has referred patients for this treatment with favorable results.

Other topics this week include The US Preventive Services Task Force 2017 Draft Recommendation Statement on Screening for Prostate CancerAn Invitation to Review and Comment, also in JAMA and which Rick encourages everyone to read and comment on, and from NEJM, Mortality and Cardiovascular Disease in Diabetes and Incidence Trends of Diabetes among Youths. Until next week, y'all live well.

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