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Running time: 18 minutes In California, Garen Wintemute and his group find evidence that people are willing to discuss gun safety with their clinicians, especially when there may be danger of harm present. That willingness extends across gun owners and non-owners. So why aren’t more clinicians doing it? The findings appear in Health Affairs. Links to the article & further resources: Health Affairs article Wintemute’s essay in Annals of Internal Medicine on gun violence Another Annals article on preventing gun-related death and injury The post Podcast 241: Talking about guns with patients first appeared on Clinical Conversations.

Running time: 23 minutes Paula Byrne set out to understand what the available data tell us about how many people are taking statins for primary prevention — and how much good is it likely doing them? Also, how do you discuss their possible harms and benefits with patients? Links: Paula Byrne and colleagues’ analysis in The BMJ Kausik Ray meta analysis in JAMA Internal  Medicine Kausik Ray 2010 Clinical Conversations interview NEJM Journal Watch General Medicine comparison of statin guidelines The post Podcast 240: Overuse of statins for primary prevention of cardiovascular events first appeared on Clinical Conversations.

Running Time: 18 minutes Veterans Day will be here soon, and this episode introduces you to Patrick Tripp, a writer and radiation oncologist. He’s taken conversations with some of his patients and published thumbnail profiles of several in a remarkable essay in the London Review of Books (that’s right, it’s not a medical journal). The patients all happened to be veterans of the war in Vietnam. There are no biomedical insights here — or are there? At the very least, you are reminded that the people in the exam room all have stories to tell, and if you have the luxury of listening to them you may just learn more about their true chief complaint. Patrick Tripp’s London Review of Books essay The post Podcast 239: Talking with veterans first appeared on Clinical Conversations.

Running time: 21 minutes A white paper from the Office of the Assistant Secretary for Preparedness and Response (ASPR) advises clinicians, health planners, and emergency responders that the old ways of responding to mass casualty events no longer hold. Wounded people arrive in Ubers and Lyfts at hospitals that are unprepared to be trauma centers. It’s best to practice (sending out an email to the staff doesn’t count) so that everyone in the hospital knows what to do and where to go when chaos strikes. Ali Raja and Joe Elia talk with Paul Biddinger, one of the contributors to “Mass Casualty Trauma Triage: Paradigms and Pitfalls.” And by the way, you may think you know how to use a tourniquet, but you probably don’t. Follow the link (below) to Stop the Bleed. Links: ASPR white paper Stop the Bleed home page Boston Marathon interviews: Ron Walls, Brigham & Women’s Hospital Alasdair Conn, Massachusetts General Hospital Andrew Ulrich, Boston Medical Center Brien Barnewolt, Tufts Medical Center NEJM Journa

Running time: 18 minutes JAMA has just published an analysis of the latest findings regarding waste in the nation’s $3.5 trillion annual health “co-pay.” And with 25% of that — some eight hundred billion dollars — characterized as wasted, you’d think there would be stacks of competing cost-saving proposals to consider, especially regarding administrative costs. There aren’t. An editorial comment on all this by our guest, Don Berwick, reminds us that one person’s wasteful spending is another’s lavish income. The question is, with all that money left on the table, what are we foregoing as a country? Dr. Berwick has thoughts, and he kindly agreed to share them with us. JAMA article by Shrank et al. JAMA editorial by Berwick The post Podcast 237: U.S. health spending — where is the outrage? first appeared on Clinical Conversations.

Running time: 20 min. Recently, Lancet Digital Health ran a meta-analysis concluding — if cautiously — that “deep learning” (more familiarly known as artificial intelligence) can be considered “equivalent to healthcare professionals” in image-based diagnoses. In an editorial commentary on the analysis, Tessa Cook says, in effect, “not so fast!” And she discusses the reasons behind that caution with us in this episode. Dr. Cook’s commentary in Lancet Digital Health The meta-analysis on which she was commenting The post Podcast 236: Is an AI better at diagnosis? first appeared on Clinical Conversations.

Running time: 18 min. Laura Hawks and colleagues undertook a study of forced sexual initiation — that is, a woman’s first episode of vaginal intercourse (and it’s forced when it wasn’t voluntary on her part). Using government survey data on some 13,000 women of reproductive age, Hawks compared the women whose sexual initiation was voluntary with those whose wasn’t. It turns out that there were longer-term medical consequences apparently associated with the circumstance. Listen in. Links: JAMA Internal Medicine article JAMA Internal Medicine editorial The post Podcast 235: Forced sexual initiation and its clinical aftermath first appeared on Clinical Conversations.

Running time: 21 minutes A national sample of early- to midcareer pediatricians shows that women are lagging behind men in compensation, and another study from the sample shows that they’re not getting much help with the housework, either. We talk with two of the authors of these studies and get their advice on what to do next — besides emptying the dishwasher and folding some laundry, gentlemen. Links: Pediatrics article on earnings Pediatrics article on housework help Pediatrics editorial on the two articles The post Podcast 234: Pay for women pediatricians lags first appeared on Clinical Conversations.

Using “Vitamin H” (haloperidol) or newer antipsychotics to treat delirium in hospitalized patients should be off the menu, writes Edward Marcantonio in an Annals of Internal Medicine editorial. Dr. Marcantonio agrees with the authors of a systematic review who conclude that “current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.” In his commentary entitled “Old Habits Die Hard,” he writes “the findings presented are sufficient to stop this clinical practice.” Links: Annals of Internal Medicine editorial Marcantonio’s “Clinical Practice” article in NEJM in 2017 The post Podcast 233: Antipsychotics are no solution to delirium during hospitalization first appeared on Clinical Conversations.

You surely remember “O-chem” — those late-night undergraduate hours spent grappling with benzene rings and alkanes and all the rest. Well, it turns out that drug makers were paying close attention to things like racemic mixtures and enantiomers. The manufacturers usually release their products as racemic mixtures and then, when patents are about to expire, an enantiomer appears. Voila! New drug, new price! Dr. Joseph Ross and his crew looked at the implications to Medicare spending of all this. They published an interesting letter in the Annals of Internal Medicine detailing how much money the system could save if we stuck with the racemic mixtures. How much? Well, on the order of $15 billion over 5 to 6 years. Links: Annals of Internal Medicine letter NEJM Journal Watch Pediatrics and Adolescent Medicine coverage of albuterol vs. levalbuterol The post Podcast 232: Basic organic chem and drug pricing first appeared on Clinical Conversations.

Dr. Eric Caine’s editorial in the Annals of Internal Medicine offers a skeptical, yet respectful, take on the evidence supporting the recent suicide-prevention guidelines from the U.S. Department of Veterans Affairs. What are other countries doing to address suicide? It has increased in the U.S. from about 10.4 per 100,000 residents in the year 2000 to about 14.5 in 2017. Do firearm restrictions help? Better household safety? And how does the U.S. rate compare internationally? Links: Annals of Internal Medicine editorial VA guidelines as published in the Annals OECD stats on international suicide rates The post Podcast 231 — The evidence behind VA’s suicide-prevention guidelines first appeared on Clinical Conversations.

The Hospital Readmissions Reduction Program (HRRP for short) seems to be reducing 30-day readmissions — but what about revisits to facilities within those 30 days? Rishi Wadhera and his co-authors measured readmissions, plus treat-and-discharge ER visits, plus stays in observation units among some 3 million Medicare discharges of a near-4-year span. They found that broadening the definition of readmissions to include not only formal returns to the hospital for a standard stay but also those ER and observation-unit encounters tells a different story. It’s a story that should make HRRP’s administrators rethink what should be measured and how expanding the definition of readmissions could benefit patients by truly promoting better quality-of-care. Links: Article in The BMJ on readmissions Earlier article in JAMA on readmissions for heart failure The post Podcast 230 — Hospital-readmissions gaming? first appeared on Clinical Conversations.

Patients with atrial fibrillation who undergo surgical procedures need special attention because their anticoagulant medications, if not adjusted, increase their risk for bleeding. Those on direct-acting oral anticoagulants — or “DOACs” — face special problems because assays for the amount of drug on-board before surgery are not routinely available. Dr. James Douketis and international colleagues have a simpler approach in their PAUSE study. On the basis of the known pharmacokinetics of DOACs, they dispense with coagulation testing and heparin bridging. Their approach involves assessing the likelihood of the procedure to cause bleeding. For low-risk procedures, DOACs are suspended a day before and resumed a day after; for riskier procedures, like resections, it’s two days before and two after. The drugs under study were apixaban, dabigatran, and rivaroxaban. We discuss the PAUSE results with Dr. Douketis. LINKS: JAMA Internal Medicine paper on PAUSE study Physician’s First Watch summary (with links to other r

Matthew Nielsen and colleagues found almost 80 diagnostic algorithms for working up a finding of hematuria. From these, they chose five representative approaches, ranging from those based on the patients’ risk factors to more aggressive ones that stress CT imaging for all. Using a 100,000-patient simulated cohort, Nielsen’s group found that more intensive imaging found more cancers than the other approaches. However, radiation-induced cancers from CT wiped out that advantage. Join us as Dr. Nielsen walks through his findings and their clinical implications. The work appeared in JAMA Internal Medicine. Links: JAMA Internal Medicine article NEJM Journal Watch General Medicine summary of ACP guidance on evaluating hematuria (from 2016) American Urological Association guideline (from 2012) The post Podcast 228: Hematuria — should the workup include imaging? first appeared on Clinical Conversations.

Chronic kidney disease, being a “prothrombic state,” would seem to warrant use of anticoagulants, yet they aren’t often used — why? The problem seems to be a lack of data with which to evaluate their effectiveness and possible harms. Big drug trials seem to avoid recruiting these patients, especially those in the later stages of CKD, where, for example, the risk for thromboembolism is two- to three-fold greater than in patients with normal kidney function. We talk with Dr. Sunil Badve, senior author of a meta-analysis in a recent Annals of Internal Medicine. His findings? Non-vitamin K oral anticoagulants (or “NOACs”) seem better suited for those with early-stage disease than vitamin K antagonists like warfarin. In later-stage CKD, there just isn’t enough data available yet, and so the choice of therapy — if any — must weigh benefits against harms carefully. Links: Annals of Internal Medicine meta-analysis Physician’s First Watch coverage The post Podcast 227: Chronic kidney disease and anticoagulants first

Length: 18 minutes Sandro Galea, dean of Boston University’s School of Public Health, has written a new book. It’s called “Well: What we need to talk about when we talk about health,” and it’s the centerpiece of our discussion. Dr. Galea, who trained as an emergency physician, believes that health is a public good and thus worthy of public investment in the things that will promote health in the future, like public education, breathable air, drinkable water, and the like. Listen in. The book is available through Amazon or your local bookseller. It’s published by Oxford University Press. The post Podcast 226: What we need to talk about when we talk about health first appeared on Clinical Conversations.

Does the diabetes care afforded by NPs and PAs match that of MDs? According to a careful analysis among Veterans Affairs patients there are no clinical differences in intermediate outcomes — hemoglobin A1c, systolic pressure, or LDL cholesterol. The principal and senior authors of that analysis are our guests this time. Links: Annals of Internal Medicine study (free abstract) Annals editorial (Annals subscription required) The post Podcast 225: Managing diabetes in primary care — are there quality differences among NPs, PAs, and MDs? first appeared on Clinical Conversations.

Rohan Khera wrote an editorial in The BMJ to accompany his own paper on guidelines for hypertension treatment. In it, he wrote, not about his research, but about the way biomedical articles are published now, and how preprint servers could change that. (In essence, pre-print servers are online repositories of rough drafts of research available for all to see; articles on such servers have not been subjected to peer review.) Khera’s research article, it should be noted, originally appeared months earlier in draft form on BioRxiv, a biomedical preprint server. Khera argues that the “official” journals are too slow. He fears their slowness. for instance, can prevent important data from reaching policymakers when it’s most needed — while they are making decisions based on new research languishing in the standard publication process. Khera’s BMJ commentary Khera et al.’s preprint on BioRxiv Khera et al.’s resarch article as published in The BMJ Conversation with Harlan Krumholz (from 2016): “Rethinking what medica

If adopted, last December’s ACC/AHA guidelines on what pressure levels signal hypertension would label almost two thirds of the U.S. population between ages 45 and 75 as having the condition. The number of people who would be candidates for treatment would almost double — from 8 million to about 15 million. What are the implications of this for clinicians? Harlan Krumholz, senior author of an analysis in The BMJ, talks about the problems and the opportunities for collaboration with patients. BMJ article (free) The post Podcast 223: What are the implications of the BP guidelines? first appeared on Clinical Conversations.

This time we talk with Dr. Hilary Barnes, first author of a Health Affairs paper: “Rural and Nonrural Primary Care Physician Practices Increasingly Rely on Nurse Practitioners.” I thought listeners might want to know more about the dramatic change in the way primary care is acquiring, in Barnes’s words, an “increasing interdisciplinary character.” Health Affairs abstract The post Podcast 222: Growing prominence of NPs in primary care first appeared on Clinical Conversations.