A weekly blog based on PodMed, Johns Hopkins podcast looking at the top medical stories of the week for people who want to become informed participants in their own health care.

Should you fast? Advocates of fasting believe it improves human longevity, perhaps via a mechanism of reduced inflammatory factors and things like LDL cholesterol. Now comes a study Rick and I discuss on PodMed this week and published in JAMA Internal Medicine that seems to refute this assertion, at least in the setting of weight loss. The specific aim of this study was to assess whether alternating days of fasting, with calories restricted to 25% of each subject's daily energy needs, versus standard caloric restriction of 75% of energy needs daily, or no intervention produced more, sustainable weight loss and improvement in cardiovascular risk factors.

100 adult participants with an average BMI of 34 were randomized to six months of the intervention or control followed by six months of follow-up. The study found that alternate fasting did not improve weight loss or sustainability, and that LDL cholesterol was actually higher in the fasting group relative to the daily caloric restriction group. Other metabolic markers, including blood pressure, heart rate, triglycerides, fasting glucose, fasting insulin, insulin resistance, C-reactive protein, or homocysteine concentrations at month 6 or 12, were the same between groups. Moreover,  about 40% of the fasting group dropped out of the study, finding compliance simply too difficult. Hmmm. Sounds like for either weight loss, maintenance, or improvement of metabolic risk factors alternate day fasting isn't helpful.

Other topics this week include Effect of Insulin Degludec vs Insulin Glargine U100 on Hypoglycemia in Type 1 Diabetes and in Type 2 diabetes in JAMA, Declining Risk of Sudden Death in Heart Failure in NEJM, and in JAMA Pediatrics, Educational and Health Outcomes of Children Treated for Attention-Deficit/Hyperactivity Disorder. Until next week, y'all live well.

We're all about self these days, it seems. Selfie sticks, self-testing for any number of infectious diseases, and now self-vaccination! While some of the emphasis on self may be suspect, Rick and I agree on PodMed this week that a novel method for self-vaccination appears to have nothing but upside, as published in the Lancet.

Researchers describe a phase I study in which 100 volunteers were randomly assigned to one of four groups: a group that received a single dose of inactivated flu vaccine via injection, or by microneedle patch, or placebo- all administered by a provider, or a self-administered patch applied by the subject. Said patch, pictured above, has tiny little dissolvable needles that have a bit of the vaccine adhered to them. When applied for several minutes, the vaccine is delivered through the skin and elicits an immune response. How good an immune response? Every bit as good as the traditional injection, their data show.  And there are a multitude of other advantages: no cold storage chain needed, easy and preferable for the majority of subjects, inexpensive, and safely disposable after use. Rick and I are looking forward to further studies, and hope to see the technology employed for many other vaccinations.

Other topics this week include two from NEJM: Air Pollution and Mortality in the Medicare Population and Aspirin vs. Placebo for Preterm Preeclampsia, and in the BMJ: Physical activity, cognitive decline, and risk of dementia: 28 year follow-up of Whitehall II cohort study. Until next week, y'all live well.

Teenagers 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.

If 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.

Getting 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.

Keeps 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.

Does 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 Adults: A 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.

Endometriosis 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.

Scientific 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.