Alasdair Conn, chief of emergency services at Massachusetts General Hospital and an associate professor of surgery at Harvard Medical School continues our series on the aftermath of the Boston Marathon bombings.

Thank you for listening. Do let us know what you think.

Joe Elia

Links:

Dr. Conn’s essay in the Annals of Internal Medicine

Last week’s conversation with Dr. Ron Walls

Thank you for your questions about the status of Clinical Conversations. We’re edging our way back toward a normal schedule with this, the first of a planned multipart series on the lessons learned in the aftermath of the Boston Marathon bombings.

Ron M. Walls, professor and chair of the department of emergency medicine at Brigham and Women’s Hospital and Harvard Medical School is the guest. Listen in and please let us know what you think.

Joe Elia

Link:

The JAMA “Viewpoint” piece written with Michael Zinner.

Running time: 20 min.

In some diseases there are two diagnoses to make: the clinical diagnosis and the diagnosis of what the patient’s treatment preference is. The first is hard enough to make, and the widening choice of treatment choices complicates the second.

Welcome to the task of “preference diagnosis,” which can lead to disappointment and worse if missed in diseases like breast or prostate cancer.

We talk this week with the authors of an essay on the topic in BMJ. They offer some advice and some resources you’ll find useful.

Links:

• First Watch coverage (free)
• “Option grid” from Cardiff University (free)
• BMJ essay (free)

Our conversation explores the question that Dr. Marcia Angell poses in a recent essay in the New York Review of Books: May doctors help you to die?

Angell’s is the first name to appear as the sponsor of a November 6 ballot initiative here in Massachusetts, which is modeled on the Oregon law already in place.

I’d expect there to be some disagreement with her arguments, and you’re welcome to leave some feedback at 617-440-4374. I’d like to include them as part of the next podcast.

Here are some links:

1. Angell’s essay in the New York Review of Books

2. Information on the ballot initiative from Ballotpedia

3. The full text of the “Massachusetts Death with Dignity Act”

A chat with clinician-essayist Cameron Page, whose essay “They Paved Paradise and Put Up a Parking Lot” appears in this month’s Health Affairs.

Our conversation explores the connections in medicine that link outside the clinic walls, with stops along the way at William Carlos Williams, Richard Seltzer, the Yankees, and more.

We get around to low back pain, eventually. Join us for a summer kick-off conversation

Health Affairs essay (free)

Dr. Peter Bach is the first author on a new JAMA analysis of the benefits and harms of using low-dose CT screening  for lung cancer. The American College of Chest Physicians and the American Society of Clinical Oncology requested the systematic review to assist them in drawing up a clinical guideline.

Join us in discussing who might most benefit from being offered such screening, and what work remains to be done.

Links:

JAMA article (free)

Physician’s First Watch coverage of recent guidelines from the American Lung Assoc. (free)

Dr. Arnold Relman, longtime observer of the U.S. healthcare system and editor emeritus of the New England Journal of Medicine, proposes two major reforms: First, private insurance companies should leave the healthcare field, and second, physicians should organize into multispecialty practices.

His proposals, just published in BMJ, grow out of his alarmed observation — some 30 years ago in the NEJM — of the rise of the “new medical-industrial complex.”

Links:

BMJ essay (free abstract)

NEJM 1980 article (free abstract)

Heart failure brings problems associated with hypercoagulation, such as stroke and sudden death.

An international study followed some 2300 patients with heart failure (ejection fractions of 35% or less) and in stable sinus rhythm for a mean of 3.5 years, randomizing them to treatment with either warfarin or aspirin.

The two treatment groups showed about the same risks for stroke and overall mortality, but warfarin was associated with more major bleeding episodes.

Our guest is the first author on the report, released online by the New England Journal of Medicine.

Links:

NEJM article

About half of adolescents with type 2 diabetes fail treatment with metformin alone within a few years. Things go somewhat better with metformin plus an intensive lifestyle intervention, and better still with the addition of rosiglitazone to metformin — however even the addition of the second drug leads to treatment failure about 40% of the time.

What’s to be done? On the basis of the evidence collected by the TODAY investigators, the problem has as many metabolic as social dimensions. Clearly, drugs alone are not the answer here.

Dr. Phil Zeitler, the TODAY study chair talks with Clinical Conversations about his surprise at the higher rate of failure with metformin monotherapy among adolescents than among adults, and what lessons this study holds.

Links:

Physician’s First Watch summary (free)

New England Journal of Medicine article (free)

New England Journal of Medicine editorial (free)

The American Heart Association’s scientific statement on “Periodontal Disease and Atherosclerotic Vascular Disease” is likely to raise hackles among those offering treatments for gum disease as a way to lower risk for heart disease — or even to ameliorate it. The association’s writing committee, after a 4-year review of the evidence, finds no support for such treatments and calls any assertions to the contrary “unwarranted.”

We interview the Dr. Peter Lockhart, co-chair of the AHA’s committee.

Links:

American Heart Association statement (free)

Influenza A (H3N2)v — a novel flu virus that emerged last summer and shows signs of being able to transmit itself from person to person — is our topic this week.

The virus carries genes from swine and avian flu viruses, and the few cases found in the U.S. all made complete recovery.

We talk with CDC epidemiologists involved in assessing the threat, and they’re reassuring on two fronts: first of all, most of the population shows at least some cross-reactive antibody to the virus; and second, they’ve isolated a candidate vaccine virus that they would use in the event that A (H3N2)v started showing increased ability for person-to-person transmission.

Links:

• MMWR article on influenza A (H3N2)v antibodies (free)
• CDC advice on treating influenza A (H3N2)v (free)
• Physician’s First Watch coverage (free)

After stroke or transient ischemic attack, depression is more common than among the general population, and the risk for depression extends beyond the early time period after the event.

More alarmingly, less than a third of those with persistent depression — defined as depression detected both at 3 and 12 months after the cerebrovascular event — receive antidepressant medication.

We offer an interview with Dr. Nada El Husseini, first author of a study published online in Stroke that presents the data supporting those observations.

Link:

Stroke abstract (free)

Physician’s First Watch summary (free)

A BMJ meta-analysis suggests that people with the highest levels of white rice consumption are at increased risk for type 2 diabetes.

The authors examined four studies, together comprising some 350,000 subjects. Two were done in Asian populations and two among Westerners. They found a much higher intake of white rice among Asians, and a strong association between consumption level and risk. In Western populations, the association was suggestive, but not as strong.

The effect may possibly derive from the higher glycemic load with increasing consumption, or from the nutrients stripped away with the rice husk during milling.

The senior author, Dr. Qi Sun, discusses his findings with us in a brief interview.

Links:

BMJ article (free)

In the largest study of its kind, UK researchers find that helping pregnant women to quit smoking until at least delivery isn’t helped much by nicotine replacement therapy.

The primary outcome, self-reported cessation lasting between the start of therapy and delivery, differed little between the active treatment group and those randomized to placebo (9% versus 8%).

In addition, compliance was low in both groups.

Links

New England Journal of Medicine abstract (free)

Everyone “knows” that colonoscopy reduces risks of death from colorectal cancer, but it’s good to have your knowledge actually verified, and a new bit of research seems to do that in this case.

Long-term follow-up of a group of patients who underwent colonoscopy and polypectomy in the 1980s shows that removal of adenomatous polyps brought with it a risk of dying from colorectal that was half the risk found in the general population. About 80% of these patients, it should be mentioned, underwent strict surveillance for 10 years after their adenomatous polyps were excised.

This is good news, no? And it offers clinicians a “teaching moment” with their patients who are reluctant to undergo the procedure.

Listen in as we interview Dr. Ann Zauber, first author on the New England Journal of Medicine paper.

Links:

Physician’s First Watch coverage of the research (free)

New England Journal of Medicine abstract (free)

New England Journal of Medicine editorial (subscription required)

Current guidelines find no compelling therapeutic benefit to screening for cognitive impairment and dementia in primary care. The Journal of the American Geriatrics Society has published some research that, if not compelling, certainly suggests that clinical approaches should change.

In actively screening some 8000 veterans over age 70 during routine primary care visits for cognitive impairment, researchers found a quarter to have signs suggesting further investigation was needed. When all was said and done, 11% had cognitive impairment; that’s two to three times the rate found in settings where physicians waited for impairment to manifest itself clinically.

We interview the lead author, who offers reasons why he thinks simple screening should be routine in elderly populations, despite the current absence of treatments for mild cognitive impairment and dementia.

Links:

Physician’s First Watch coverage (free)

Journal of the American Geriatrics Society abstract (free)

USPSTF current screening guidelines (free)

Mini-Cog screening test (free)

Haplogroups — who knew? Ancient variations in the Y chromosome form what’s known as haplogroups, and haplogroup I is common in Europe, particularly so in northern Europe. Researchers find that “I” is an independent risk factor for coronary artery disease in men, carried as it is on the male-only Y chromosome.

Listen in as we talk ancient genetics and what it all could mean for a range of immune-system-related diseases. There’s plenty of work to be done, but we thought you ought to know about this earlier rather than later.

Links:

• Physician’s First Watch coverage (free)
• Lancet abstract (free)

PPIs are back on our radar, and this time it’s their regular use among postmenopausal women.

A BMJ article examines data from the Nurses’ Health Study to show a significantly increased risk for hip fracture among postmenopausal women with any smoking history. Never-smokers showed no statistically significant increase.

Now that proton pump inhibitors have been available over-the-counter for the better part of a decade, should clinicians be asking about their patients’ smoking history in concert with asking about how they handle heartburn?

Links:

BMJ article (free)

Physician’s First Watch summary (free)

FDA’s May 2010 warning on PPIs and fracture risks (free)

Controlling asthma by the use of proton pump inhibitors apparently doesn’t work any better in children than it does in adults. Yet the practice is widely used.

A study in JAMA and an accompanying fiery editorial seem to put the notion to rest. Listen in.

As always, suggestions are welcomed. You can reach me directly at 617-440-4374 — don’t be shy!

Links:

• JAMA study coverage in Physician’s First Watch (free)
• Earlier (2009) Clinical Conversations podcast #38 with Dr. Robert Wise on the effect of PPIs in adult asthma (free)

The American College of Physicians wants to encourage high-value, cost-conscious care. And so they convened a consensus panel of physicians to list tests that they considered overused or inappropriately used in certain circumstances. One example would be the use of MRI for breast screening in normal-risk patients; another is the use of imaging studies in the diagnosis of nonspecific low-back pain.

The panel came up with about 40 such examples, and the ACP is inviting your reactions (and suggestions for further examples) on a survey available on its website, a link to which is in the list below.

Meanwhile, listen in on a 15-minute conversation with Dr. Amir Qaseem, the first author of the panel’s report, just published in the Annals of Internal Medicine. An editorial on the report cites a Congressional Budget Office study estimating that 5% of the nation’s GDP is misspent on medical tests and procedures that don’t help the patient. That’s fully 25% of all health expenditures! Houston, we have a problem….

Links:

Physician’s First Watch coverage (free)

Annals of Internal Medicine article (free abstract)

ACP survey form (free access)

Yes, it apparently does.

An international study in the New England Journal of Medicine monitored subclinical atrial fibrillation among some 2600 patients who’d just received an implanted pacemaker or cardioverter-defibrillator.

After 3 months of monitoring, about 10% of the group showed subclinical episodes of afib lasting at least 6 minutes.

Over an additional 2.5 years of follow-up the patients initially showing subclinical afib were found to have at least twice the risk for stroke or systemic thromboembolism compared with the rest of the group.

What does it all mean to clinicians? Should anticoagulation measures be taken in patients showing subclinical afib?

Dr. Stuart J. Connolly, one of the study’s principal authors, chatted with Clinical Conversations, offering some clinical guidance on what to do while the apparent magnitude of the effect is investigated further.

Links:

Physician’s First Watch coverage (free)

New England Journal of Medicine abstract (free)

The new edition of the American College of Physicians Ethics Manual has just been released, and at 30 pages, it’s well worth the reading time.

It’s available free online as a supplement to the Annals of Internal Medicine. New or updated topics include social media and online professionalism, interrogation of prisoners, and allocation of medical resources.

In discussing the relation of the physician to the government, the manual states unequivocally: “Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being….”

Listen in to our chat with two of the people on the committee that put the new edition of the manual together

Links:

• Physician’s First Watch coverage
• American College of Physicians Center for Ethics and Professionalism web site (free)
• Supplement to the Annals of Internal Medicine (free)
• Annals editorial (free)

A double-blind crossover study in the New England Journal of Medicine shows that 3 months of continuous positive airway pressure (CPAP) in patients with moderate to severe obstructive sleep apnea ameliorates some components of the metabolic syndrome, which is present in about three quarters of such patients.

The authors acknowledge the difficulty of motivating patients to use CPAP consistenly, which could limit its use in routine practice, and they stress the need for counseling to accompany any CPAP prescription.

Links:

Physician’s First Watch coverage (free)

New England Journal of Medicine article (free)

When kids go for ambulatory care, they get an antibiotic prescribed about 20% of the time. Half of those antibiotics are of the broad-spectrum variety.

What are the factors leading up to this, and what are some resources to turn to for better information on this dangerous situation?

Listen in to  this 27-minute podcast with the first author of a Pediatrics study examining the issue.

Links:

Physician’s First Watch coverage of the Pediatrics paper (free)

Get Smart: Know When Antibiotics Work (free CDC site mentioned by Dr. Hersh)

Get Smart for Healthcare (free CDC site)

Rising Plague by Brad Spellberg (book mentioned by Hersh)

ASM statement on the GAIN Act (legislation mentioned by Hersh)

A study from Sweden shows that immediate clamping of the cord at birth isn’t such a great idea from the standpoint of the baby’s iron stores.

BMJ‘s editorialist thinks it may be time to change practice in this area.

Listen in — this will be on the test!

Physician’s First Watch coverage

BMJ article

BMJ editorial

Last week’s Lancet article on the effect of aspirin on risks for colorectal cancer in patients with Lynch syndrome — a group at particularly high risk — may hold implications for preventing sporadic colon cancers.

Our interview with Prof. Sir John Burn, the study’s first author, explores those implications as well speculations on why  we human beings aren’t getting the salicylates we were when our vegetables weren’t so pampered.

Links:

• Physician’s First Watch coverge (free)
• Lancet abstract (free)
• NEJM 2008 paper (free)
• The CAPP3 website

The quadrivalent HPV vaccine was effective at preventing anal intraepithelial neoplasias in men who have sex with men, it was reported last week.

The larger question is how to get it to young men before they become sexually active.

We interview Dr. Joel Palefsky of UCSF, the first author on a paper in the New England Journal of Medicine that demonstrates the vaccine’s efficacy.

Links:

• NEJM abstract
• Physician’s First Watch summary
• CDC’s sexually-transmitted diseases web site (mentioned by Palefsky as a good, impartial resource on these questions)

Barrett’s esophagus no longer carries the promise of esophageal cancer that it seemed to, but it bears watching, especially in the first year after the finding, when most cancers are found.

The first author of this week’s New England Journal of Medicine study tracking the progression of a finding of Barrett’s over a median 5-year period offers some advice on how to proceed.

Links:

• Physician’s First Watch summary
• NEJM abstract

A cluster of clear-cell adenocarcinomas of the vagina in young women led to the realization some 40 years ago that almost all their mothers had taken diethylstilbestrol during pregnancy — a drug in wide use in the early 1950s.

In a follow-up to that drug disaster, researchers (including one of the authors of the original reports in the early 1970s) have examined reproductive health in a large cohort of women exposed to DES in utero.  Their results were published last week in the New England Journal of Medicine, and they show that the health effects apparently continue beyond the reproductive years. With that cohort — the baby boomers — now entering the stage of their lives when health visits start to increase, it’s worthwhile for clinicians to be briefed on these long-term effects.

This week, we talk with two authors of the new report.

Links:

Physician’s First Watch coverage (free)

NEJM article (free abstract)

Words really do matter, and for clinicians discussing a child’s overweight with parents, words can hurt, stigmatize, and discourage parents from taking the right actions.

In a brief interview, the author of a Pediatrics study talks about the best approach to take in these discussions. There are no “magic words,” rather the approach should involve asking parents what words they feel most comfortable using in talking about how to address the problem.

Links:

• Physician’s First Watch summary (free)
• Pediatrics article (free)