iStock-485935060C.dif is the abbreviation for one scourge of modern healthcare: an infection that often results in severe diarrhea, is challenging to treat, recurs readily, and may result in death. Now, as Rick and I discuss on PodMed this week and published in the New England Journal of Medicine, hope has arrived in the form of a new antibody to treat C. dif, or Clostridium difficile.

Turns out there are two antibodies against toxins produced by the organism reported in NEJM this week, but only the one against toxin B, known as bezlotoxumab, turned out to be much help. Over 2500 adults with primary or recurrent C.dif infection were included in this study, all of whom received standard oral antibiotics, followed by one or both antibodies or placebo. Those who received bezlotoxumab were more likely to achieve a sustained cure, that is no recurrence after initial clinical cure within 12 weeks, than those who received both antibodies or placebo.

The antibodies were administered by a single IV infusion following routine antibiotic therapy. The most common side effects reported by 2% of subjects included nausea and headache. Rick and I agree that these are impressive results and might be improved with more than one dose of the antibody or combination with fecal transplant.  Rick also advised me that the drug has just been approved by the FDA, so should soon be available widely.

Other topics this week include Association of Patient-Physician Language Concordance and Glycemic Control for Limited–English Proficiency Latinos With Type 2 Diabetes in JAMA Internal Medicine, a method for assessing medical devices once they're on the market Prospective Surveillance of Medical-Device Safety in NEJM, and Physician Decision Making and Clinical Outcomes With Laboratory Polysomnography or Limited-Channel Sleep Studies for Obstructive Sleep ApneaA Randomized Trial in Annals of Internal Medicine. Until next week, y'all live well.

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iStock-504309690High blood pressure or hypertension is a well-known risk factor for heart attack and stroke. And while there is currently a lot of controversy over exact blood pressures to be targeted in different populations, one group of people remains especially problematic: those with slightly high blood pressure. These folks aren't clearly at risk for a cardiovascular event and no one wants to use medicines daily if they aren't really needed. Now a new study from Johns Hopkins published in Circulation that Rick and I discuss on PodMed this week may help.

Hopkins researchers used data from a long term study known by the acronym MESA for Multi-Ethnic Study of Atherosclerosis. Blood pressure measurements as well as routine risk calculators were used to calculate cardiovascular risk for over 3700 participants. Then researchers added coronary calcium scoring, a quick, noninvasive CT scan of the heart, to the mix. They found that adding this score was able to much more accurately inform which of those subjects with slightly elevated blood pressure would benefit from using blood pressure lowering medication. As Rick and I note in the podcast, however, the real proof of utility will come when a prospective study is done on this group of people, but for now, it helps inform decision making.

Other topics this week include two from JAMA: Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma and Association Between Diabetes and Cause-Specific Mortality in Rural and Urban Areas of China, and a look at tonsillectomy in Pediatrics: Tonsillectomy Versus Watchful Waiting for Recurrent Throat Infection: A Systematic Review. Until next week, y'all live well.

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iStock-183991779Wow.  Hard as it is for me to believe, Rick and I focus our attention this week on PodMed on the subject of ear wax, or cerumen, as it's known among the medical tribe.  Why is that?  Because the American Academy of Otolaryngology has published new guidelines on the subject, and it's a lot more impactful (boo!) than we were aware.

Rick points out in the podcast that there are certain groups who are at high risk to have ear wax accumulate and become impacted in the ear canal, including the elderly, small children, those who wear hearing aids and those who live in nursing homes or have dementia. In fact one in ten people may suffer from such a condition. When cerumen becomes impacted hearing can clearly be affected, but a sensation of fullness and even infection can also result. Getting the stuff out is more problematic than you may think; the adage I heard many years ago about never inserting anything larger than your elbow in  your ear is once again invoked.  Cotton tipped swabs may actually make the problem worse and are not recommended.  Folks are advised to see their primary care doc, who can first visualize whether there is a problem, and then use either mechanical means to remove it or chose among several agents to dissolve it. Even this choice may be complicated by whether someone is on a blood thinner or has other medical conditions.  Who knew? Guess we're glad they stepped up to this.

Other topics this week include Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative CareA Randomized Clinical Trial in JAMA Internal Medicine, and two from Annals of Internal Medicine:

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iStock-505980885Asthma is a killer, especially for children. Now a study Rick and I report on PodMed this week and published in the New England Journal of Medicine offers hope for preventing this condition by supplementing pregnant women with fish oil. Novel for sure, and able to reduce the incidence of asthma and wheezing in offspring by an impressive 30%+.  What exactly did they do?

First off it must be admitted that the study took place in Denmark, one of the places in the world where a robust and trusted healthcare system could identify, recruit, supplement women during pregnancy and track offspring for a few years after their birth.  Moreover Denmark may have been one of the few places where the a priori hypothesis that reduced consumption of omega-3 fatty acids and the observed increase in asthma and wheezing in children were related.  In any case, 736 women recruited to the study were randomly assigned to receive 2.4 grams of fish oil per day or olive oil, beginning at 24 weeks of gestation. Their children were followed for three years after birth. In short, the study found that supplementation resulted in a one-third reduction of wheezing, asthma, and upper respiratory infections among those children whose mothers took fish oil. As Rick and I comment, seems like a reasonable strategy to employ right now in all pregnant women, as the downside is almost nonexistent while the potential upside sizable.

Other topics this week include two from Annals of Internal Medicine:Readmission Rates After Passage of the Hospital Readmissions Reduction ProgramA Pre–Post Analysis and The Scientific Basis of Guideline Recommendations on Sugar IntakeA Systematic Review, and from JAMA US Spending on Personal Health Care and Public Health, 1996-2013.  Happy New Year, and y'all live well.

 

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iStock-510952418Imagine having an EEG to look at brain activity when assessing choices of underwear, specifically with regard to color.  Hmmm.  Sounds like a bunch of people, both investigators and study participants, with too much time on their hands, but there it is.  As Rick and I discuss on PodMed this week and published in the Australasian Marketing Journal (!), researchers asked 20 subjects to evaluate underwear that was red, white, blue, brown, grey or black while having a 6 channel EEG. Brain wave activity was collected from frontal, temporal, and occipital lobes, with results demonstrating a clear bilateral change in all three lobes when the subject indicated their preferred color. Most interestingly and informative for the Christmas season, women preferred red undergarments while men preferred white. Rick refers to this phenomenon as 'tighty whities' and we both agree that men who are buying their female partners underwear should take note.

Other fun topics this week include Effects of Mediterranean diet in patients with recurring colds and frequent complicationsStudy of a laboratory-scaled new method for the accelerated continuous ageing of wine spirits by applying ultrasound energy and Use of LED light for Brussels sprouts post harvest conservation. Happy reading, and a Merry Christmas!  Until next week, y'all live well.

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m_joi160106f2Where you live in the United States may have a big impact on how you die, a study Rick and I discuss on PodMed this week and published in JAMA demonstrates. We are both impressed with the shear size of this database as well as the prodigious crunching that had to take place to generate an array of illustrative graphics.  Said graphics depict the map of the United States with death from various causes represented, and illustrate the fact that the southern part of the country suffers a disproportionate amount of cardiovascular disease and death from violence. As Rick points out in the podcast, this is also where risk factors such as smoking, obesity and sedentary lifestyle are prevalent, so perhaps it shouldn't be surprising. He also points out that targeted interventions are both possible and indicated in these areas, so clearly the study is of huge public health importance.

The study in unique in that it actually calculates death rates by county, of which there are over 3000, in the United States, for the 21 most common causes of death. It also attempts to correct for so-called 'garbage codes,' relative to causes of death that don't provide any real information. Interestingly, from the over 80 million deaths that took place during the time period in this study, over 19 million were assigned garbage codes as causes of death.  This points out another public health issue relative to gathering of trustworthy data.  No doubt plenty of initiatives will result from this study, we agree.

Other topics this week include Association Between Statin Exposure and Alzheimer Disease by Sex/Race in JAMA Neurology, Demographic Differences in Adult Use of Psychiatric Drugs in JAMA Neurology, and NIDA statistics on teen substance use and abuse.  Until next week, y'all live well.

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iStock-478561284Parkinson's disease is a very common neurodegenerative disease, affecting over 50 million people worldwide in 2013, recent data estimate. And who among us hasn't seen the shaking hands and shuffling gait typical of this debilitating condition?  The bad news is the relentless progression of the disorder, with depression and dementia frequently developing. Now, as Rick and I discuss on PodMed this week and published in JAMA Neurology, an assay looking at a misfolded protein called alpha-synuclein may help in diagnosis, progression, and perhaps ultimately treatments or cure.  And the study introduces to us a new technique for amplification of small amounts of protein, which we predict will have great clinical utility in lots of conditions.

The novel technology here is called 'protein misfolding cyclic amplification or PMCA,' and it takes advantage of the fact that misfolded proteins such as alpha-synuclein cause additional aberrant protein to form, thus allowing amplification of the signal to a detectable level. PMCA was utilized to detect alpha-synuclein in the cerebrospinal fluid of 76 people with known Parkinson's disease and 65 others with a different neurological disorder. In short, PMCA was 88.5% sensitive and 96.9% specific in identifying those with Parkinson's and was also correlated with symptom severity. As Rick and I also note, it would be great to have something other than CSF to test to render PMCA more practical, but this proof of concept study is heartening.

Other topics this week are all from NEJM: Revascularization of Left Main Coronary Artery DiseaseCrizanlizumab for the Prevention of Pain Crises in Sickle Cell Disease, and Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting. Until next week, y'all live well.

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iStock-489309852People who are frail don't do as well during and after surgery as those who aren't. Duh. Now a study Rick and I discuss on PodMed this week and published in JAMA Surgery attempted to assess frailty preoperatively and develop a plan for afterward, with results that are impressive indeed.

Beginning in October 2007 to July 1, 2014, all patients who came to a single Veteran's Administration medical center for major, elective non-cardiac surgery were assessed preoperatively using a frailty index, and those who were identified as frail comprehensively evaluated by a multidisciplinary team, who created a plan for their care. Here are the results directly from the paper:

Results  From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16).

Rick and I agree that this is impressive indeed, and I am especially impressed by the statement I bolded above, that even among those who weren't deemed to be at risk such an assessment substantially improved outcomes. And among all comers, the results were durable for 180 days.  Sounds like a clear imperative to implement such a strategy globally.

Other topics this week include Accuracy of a Deep Learning Algorithm for Detection of Diabetic RetinopathySwimming, aerobics, and racquet sports are linked to lowest risk of cardiovascular death from the BMJ, and Pronounced increase in risk of acute ST-segment elevation myocardial infarction in younger smokers, from Heart.  Until next week, y'all live well.

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iStock-486792042Watching and waiting may take place too long in the UK when it comes to abdominal aortic aneurysms (AAA), a study Rick and I discuss on PodMed this week and as published in NEJM reveals, since a number of dire outcomes seem to result when repair is delayed until a certain size aneurysm is reached And as I chortle to Rick, it isn't often our interventional approach to many medical conditions is validated when compared to more conservative strategies, so this study is noteworthy to me in that regard.

Data from almost 30,000 folks who underwent AAA repair in the UK was compared in this study to almost 280,000 records from those with the same condition in the US. This was during the time period from 2005 through 2012. The impact of the higher thresholds for treatment in the UK was examined through the lens of three outcomes: death relative to the aneurysm, hospitalization relative to AAA, and likelihood of repair. The study found that AAA repair was less likely to be undertaken in the UK, that aneurysm-related death was almost four times more likely in the UK, and that hospitalization due to rupture was more than twice as likely across the pond. The average threshold for treatment was 58.3 millimeters domestically versus 63.1mm in the UK. Hmmm.  Seems like operating sooner rather than later is a better strategy, and Rick and I also note that screening, especially for older men who are current or former smokers, is also important.

Other topics this week include Symptoms and Satisfaction of Patients in the PROWL StudiesHip and Pelvic Fracture Risk Associated With Antihypertensive Medications, and a look a mumps in the US currently from MMWR http://www.cdc.gov/mmwr/index.html, along with measles surveillance.  Until next week, y'all live well.

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Neck-PainPain relief is an important part of maintaining quality of life for many, including me, so NSAIDs, non-steroidal anti-inflammatory medicines, are welcome.  But many studies have rumbled that they may be risky for your heart.  Good news then, as Rick and I discuss on PodMed this week and as published online in NEJM, at least three of them appear NOT to confer increased risk for cardiovascular events, at least in comparison to each other and with certain other caveats.  This as also revealed at the recently concluded American Heart Association meeting.

People who took part in this trial had either osteo- or rheumatoid arthritis and were randomized to either celecoxib (Celebrex), ibuprofen or naproxen at various doses daily. Just over 24,000 subjects were treated for about two years and followed for almost three. Almost 70% of participants stopped taking their drug and just over 27% discontinued follow-up. When looking for the three primary outcomes of cardiovascular death, nonfatal heart attack or stroke, no significant difference was found between the three groups, with about 2.5% experiencing such an event. Additional assessments were also made with regard to renal and gastrointestinal problems, with celecoxib emerging as the least risky.

Rick concludes from this study that at the low doses employed here, and for short duration, celecoxib appears to be safe, but we'd both like to see a more pragmatic trial with higher doses and longer treatment periods. Other topics this week include Randomized Trial of Bilateral versus Single Internal-Thoracic-Artery GraftsGenetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease, and A Highly Durable RNAi Therapeutic Inhibitor of PCSK9. Until next week, y'all live well.

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