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Podcast Description
Stay informed of the most relevant medical developments by subscribing to Clinical Conversations (http://podcasts.jwatch.org), from Journal Watch. This podcast features a round-up of the week's top medical stories, clinically-oriented interviews and listeners’ comments…in 30 minutes or less. Produced by the publishers of the New England Journal of Medicine, Journal Watch (jwatch.org) delivers independent, practical, and concise information you can trust.
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Podcast 156: Using low-dose CT screening for lung cancer in defined populations — a conversation with Peter Bach | 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) | 5/20/12 | Free | View In iTunes |
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Podcast 155: What’s wrong with U.S. healthcare and what will save it? | 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) | 5/14/12 | Free | View In iTunes |
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Podcast 154: Treating heart failure’s hypercoagulable state — warfarin or aspirin? | 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 | 5/2/12 | Free | View In iTunes |
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Podcast 153: Type 2 diabetes in young people — tough going on the treatment front | 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) | 4/30/12 | Free | View In iTunes |
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Podcast 152: Gum disease and atherosclerosis — evidence for an association, but not for a cause-and-effect | 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) | 4/18/12 | Free | View In iTunes |
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Podcast 151: Most people above age 10 have at least some cross-reactive antibodies to variant influenza | 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) | 4/14/12 | Free | View In iTunes |
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Podcast 150: Depression (and antidepressant use) after stroke or TIA | 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) | 3/29/12 | Free | View In iTunes |
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Podcast 149: High levels of white rice consumption seem linked to higher risks for type 2 diabetes | 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) | 3/15/12 | Free | View In iTunes |
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Podcast 148: Smoking cessation during pregnancy is probably more effective with behavioral approaches than with relying on nico | 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) | 2/29/12 | Free | View In iTunes |
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Podcast 147: Proof that colonoscopy with polypectomy saves lives | 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) | 2/24/12 | Free | View In iTunes |
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Podcast 146: Cognitive impairment in primary care — screen or not? | 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) | 2/17/12 | Free | View In iTunes |
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Podcast 145: The Y chromosome and the possible role of a common variant in coronary disease in men. | 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) | 2/13/12 | Free | View In iTunes |
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Podcast 144: Hip fractures, PPIs, and smoking history in postmenopausal women — increased risks | 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) | 2/3/12 | Free | View In iTunes |
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Podcast 143: PPIs and asthma control — it doesn’t work in kids, either | 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) | 1/27/12 | Free | View In iTunes |
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Podcast 142: Really, why are you ordering that test? | 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) | 1/20/12 | Free | View In iTunes |
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Podcast 141: Clinically apparent atrial fibrillation increases stroke risk; does subclinical afib do the same? | 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) | 1/13/12 | Free | View In iTunes |
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Podcast 140: A new edition of the ACP’s manual on ethics for clinicians is available online | 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) | 1/6/12 | Free | View In iTunes |
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Podcast 139: CPAP for obstructive sleep apnea seems to improve some measures of the metabolic syndrome | 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) | 12/17/11 | Free | View In iTunes |
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Podcast 138: Why do kids in the U.S. get so many inappropriate broad-spectrum antibiotics? | 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) | 12/9/11 | Free | View In iTunes |
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Podcast 137: Clamping the umbilical cord — what’s the big rush? | 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 | 11/18/11 | Free | View In iTunes |
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Podcast 136: Aspirin lowers colorectal risks in Lynch syndrome — what are the implications for everyone else? | 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 | 11/4/11 | Free | View In iTunes |
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Podcast 135: HPV vaccine effective against anal intraepithelial neoplasia in MSM. Now, how to get it to young men before they | 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) | 10/28/11 | Free | View In iTunes |
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Podcast 134: How (and why) surveillance in Barrett’s esophagus should change | 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 | 10/14/11 | Free | View In iTunes |
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Podcast 133: Over 50 years later, DES’s adverse effects continue | 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) | 10/8/11 | Free | View In iTunes |
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Podcast 132: In discussing a child’s overweight with parents, words matter | 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) | 9/30/11 | Free | View In iTunes |
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Podcast 131: Measuring the effect of the rotavirus vaccine program on kids in the U.S. | Vaccines work, and here's more evidence. The quadrivalent rotavirus vaccine introduced in 2006 has dramatically lowered hospitalizations for rotavirus-related diarrhea among children under age 5, among other benefits. Its presence has produced a kind of herd immunity whereby even the unvaccinated are reaping benefits. It bears remembering, though, that vaccinees have about a 90% lower rate of hospitalization for the illness than the unvaccinated. And as to intussusception -- a concern with an earlier rotavirus vaccine -- that risk is an order-of-magnitude less, according to field data from outside the U.S. Links: New England Journal of Medicine article (free abstract) Physician's First Watch coverage (free) ACIP recommendations for preventing rotavirus infection in kids (free) | 9/23/11 | Free | View In iTunes |
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Podcast 130: If you’re a clinician concerned about health costs, wash your hands — don’t just wring them | Health Affairs has a study in which a few simple, but rigorously followed patient-care procedures in a pediatric ICU dropped infection rates, mortality, lengths of hospital stay, and total costs. Sound too good to be true? Well, it wasn't exactly easy, but the results were real and measurable. Listen in and see whether this could work for you and your institution. Links: Health Affairs article (free abstract) Physician's First Watch summary (free) Psychological Science study of motivations for clinicians' hand washing (news release) | 9/16/11 | Free | View In iTunes |
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Podcast 129: Non-aspirin NSAIDs are associated, as a class, with spontaneous abortion in a Quebec study | Last week the Canadian Medical Association Journal published an analysis of data from the Quebec Pregnancy Registry showing that the use of any non-aspirin NSAID during pregnancy was associated with an increased risk for spontaneous abortion before the 20th week of gestation. There was no apparent dose-response effect. We discuss the research with the paper's senior author, Dr. Anick Berard of the University of Montreal. Links: -- Physician's First Watch coverage of the study (free) -- CMAJ article (free) | 9/10/11 | Free | View In iTunes |
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Podcast 128: Bleeding patients, inadvertently, into anemia happens more often than you might think | An article in Archives of Internal Medicine examines what's called "diagnostic blood loss" -- the loss of blood through phlebotomy and not hemorrhage. The effect is the same, however. According to a study conducted in 57 medical centers among some 18,000 patients with myocardial infarction, one in five became moderately or severely anemic (hemoglobin level under 11) from their hospital stay. That's a 20% rate of iatrogenic anemia. Two of the study's authors discuss the work and their proposed fixes to this problem, which most likely isn't limited to patients with MIs. Archives of Internal Medicine article (free) Physician's First Watch coverage (free) | 8/12/11 | Free | View In iTunes |
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Podcast 127: Why QALYs matter | This time we talk with Dr. Katia Noyes, first author on a study of the cost-effectiveness of disease-modifying drugs in multiple sclerosis. If you don't treat MS, don't think that the topic is irrelevant. Noyes brings the issues of cost-effectiveness and the dreaded QALY into focus for clinicians who see patients. After all, medical costs will undoubtedly become centerpieces of political debate over the next year and beyond. We'd all be better off being able to evaluate the arguments made. Noyes et al.'s article in Neurology (abstract) Physician's First Watch coverage Peter Neumann's book, "Using Cost-Effectiveness Analysis to Improve Health Care" (Amazon link) Gold et al.'s book, "Cost-Effectiveness in Health and Medicine" (Amazon link) | 8/3/11 | Free | View In iTunes |
| Total: 30 Episodes |
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