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What’s causing this resurgence, and what’s to be done? Pejman Rohani talks about his Science Translational Medicine study that used “gold standard” historical data to examine possible causes. He and his colleagues conclude that, as with mumps, slowly waning vaccine protection is at play. However, they identify the “core transmission group” as schoolchildren, who have a greater frequency of contacts. Adults, they find, have “at most a minor role.” LINKS: Science Translational Medicine abstract Proc Royal Society B review on “the pertussis enigma” Podcast 220 on mumps resurgence The post Podcast 221: Pertussis makes a comeback — kids have an outsize role first appeared on Clinical Conversations.

Mumps outbreaks keep happening, even among vaccinated groups. Why? Our guest, Joseph Lewnard, and his coauthor, Yonstan Grad, probed studies of mumps vaccine efficacy carried out over five decades. They show that the fault, dear clinician, is not in our vaccines or new viral strains, but in ourselves. Our bodies slowly lose their immune response after vaccination, and about 25 years after the last vaccine dose, it’s gone. Listen in. Links: Science Translational Medicine study CDC recommends a third dose of MMR vaccine in an outbreak The post Podcast 220: Mumps outbreaks — blame waning protection, not new viruses or bad vaccines first appeared on Clinical Conversations.

There simply isn’t enough evidence to sustain its continued use in asymptomatic men, argues our guest. Dr. Jason Profetto, senior author on an Annals of Family Medicine meta-analysis. Links: Annals of Family Medicine abstract Physician’s First Watch coverage The post Podcast 219: Digital rectal exams shouldn’t be routine in primary care first appeared on Clinical Conversations.

An analysis of the states’ integration of midwifery into their healthcare systems concludes that better integration led to better outcomes for mothers and babies. We discuss this with Dr. Saraswathi Vedam, the study’s first author. Links: University of British Columbia’s Birth Place Lab PLoS One article First Watch coverage of the Lancet series on midwifery The post Podcast 218: Better integration of midwifery associated with better birth outcomes first appeared on Clinical Conversations.

The EPCAT II trial examined whether aspirin and rivaroxaban were clinically equivalent in the extended prophylaxis of venous thromboembolism after hip or knee replacement. They proved “comparably effective and safe,” according to our guest, Dr. David Anderson, the study’s first author. An editorial in the New England Journal of Medicine, where the study appeared in February, calls the results practice-changing. One thing was sure from the outset — aspirin is cheaper than rivaroxaban by orders of magnitude. A note to listeners: Dr. Anderson and I conducted the interview over several sessions, so the first-half audio sounds a bit rougher than the second. Your speakers don’t suddenly get better — my equipment does! Links: NEJM report NEJM editorial Journal Watch General Medicine summary The post Podcast 217: Aspirin and rivaroxaban “comparably effective and safe” for prophylaxis after arthroplasty first appeared on Clinical Conversations.

A recent paper in JAMA Internal Medicine sought to examine what happens after breast cancer screening with magnetic resonance imaging. It reported that core and surgical biopsy rates doubled, compared with mammography, in women with a personal history of breast cancer; they rose fivefold among women with no personal breast cancer histories. Dr. Diana Buist, the study’s principal author, helps sort out the implications of this study, done on some 2 million screenings. Running time: 18 minutes JAMA Internal Medicine paper USPSTF guidelines on breast cancer screening for normal-risk women American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography National Comprehensive Cancer Network clinical practice guidelines on breast cancer The post Podcast 216: What role for MRI in breast cancer screening? first appeared on Clinical Conversations.

Timothy Hoff thinks clinicians “must finally recognize that they are indeed ‘workers’ whose ability to control their daily fates has been reduced greatly.” He worries about the continuing erosion of the doctor-patient relationship, and he wonders why the profession is so reluctant to view its members as “put-upon workers struggling to gain favorable conditions for their work within corporatized health care settings.” We talked with Prof. Hoff about his just-published book: “Next in Line: Lowered expectations in the age of retail- and value-based health.” To the barricades! “Next in Line” (link to Oxford University Press site) The post Podcast 215: Has primary care been Amazon-ized? first appeared on Clinical Conversations.

The non-vitamin-K oral anticoagulants (known familiarly as NOACs or DOACs) share metabolic pathways with other drugs, which can potentiate NOACs’ anticoagulant actions dangerously. Dr. Shang-Hung Chang and his group studied Taiwan’s national health insurance database, which records data on virtually all that nation’s citizens, to measure the actual risks of some of these drug – drug interactions. Their findings were published earlier this month in JAMA. Links: JAMA article (abstract) Physician’s First Watch coverage The post Podcast 214: Drug-drug interactions and bleeding risks with NOACs first appeared on Clinical Conversations.

Pregnant women with type 1 diabetes can realize more than better control with continuous glucose monitoring: their babies are less likely to be large for gestational age and less likely to spend time in neonatal ICUs. Dr. Denice Feig, who authored a recent international study in The Lancet, talks about her findings and makes recommendations for the future. Links: Lancet study Physician’s First Watch summary The post Podcast 213: Continuous glucose monitoring in pregnancies with type 1 diabetes first appeared on Clinical Conversations.

There was an excellent commentary accompanying a recent JAMA Internal Medicine meta-analysis: “The Ideal Blood Pressure Target for Patients with Chronic Kidney Disease — Searching for the Sweet Spot” by Csaba Kovesdy. He offers a nice perspective on the problem and kindly agreed to talk with us. Links: Kovesdy’s commentary in JAMA Internal Medicine The meta-analysis by Malhotra et al. The post Podcast 212: BP in CKD — Where’s the Sweet Spot? first appeared on Clinical Conversations.

Sometimes — but not all the time — patients can be advised to stop a course of antibiotics if they feel better. Traditionally, the advice has been to complete the entire course, regardless. Why? Because it was thought that stopping early might lead to more antibiotic resistance. That’s changing now, as the WHO and the CDC advise that courses be taken as directed by (and in consultation with) the prescriber. Prof. Martin Llewelyn and his colleagues wrote an intriguing analysis in The BMJ of the idea of stopping treatment under certain circumstances. They point out that it’s the longer duration of treatment (and thus longer exposure of commensals to antibiotics) that’s almost certainly causing most cases of resistance. Links: Article in The BMJ NEJM Group Open Forum starting Wednesday, Aug. 23 The post Podcast 211: On (not) staying the (antibiotic) course first appeared on Clinical Conversations.

Dr. Jerome P. Kassirer served as editor-in-chief of the New England Journal of Medicine from 1991 to 1999. Almost 20 years later, Kassirer looks back on his life and his time as editor in a new autobiography, titled “Unanticipated Outcomes” — and in a conversation with us. Links: Kassirer editorial on managed care. Kassirer on the digital transformation of medicine. The post Podcast 210: Jerome Kassirer — an editor looks back first appeared on Clinical Conversations.

The senior author of a paper examining the role of systemic antibiotics after incision-and-drainage in treating small skin abscesses says the results should prompt a rewriting of current guidelines. Henry Chambers of UCSF found a 15-percentage-point advantage in short-term cure rates for antibiotics over placebo. The guidelines don’t encourage systemic antibiotics in these circumstances, but Chambers’ group found the advantage held both in the intention-to-treat results and among those patients who were full adherent to their regimens. Clinical Conversations comes to you through the NEJM Group. Executive producer, Kristin Kelley. The post Podcast 209: “The guidelines need to be rewritten” to encourage antibiotic use after incision and drainage of small skin abscesses first appeared on Clinical Conversations.

Dr. David Ansell, a professor of medicine at Rush University Medical Center in Chicago, discusses his new book, “The Death Gap: How inequality kills.” What’s the death gap? Look at it this way: you’re getting on the Chicago Transit Authority’s Blue Line at “The Loop” in downtown, where the average life expectancy is 85 yrs. Go 7 stops south, and you’ll end up in a place whose inhabitants have a life expectancy of 69 — lower than that in Bangladesh. That’s a “death gap” of 16 years. It’s worse in rural America. Drive from Connecticut to rural Mississippi and see some 35 years’ life expectancy evaporate. How did the United States get here? And what are we going to do about it? Clinical Conversations comes to you through the NEJM Group. Executive producer, Kristin Kelley. The post Podcast 208: How inequality kills — David Ansell talks with us about his new book first appeared on Clinical Conversations.

All previous editions are available at podcasts.jwatch.org. I overheard this week’s guest, Zain Kassam, discussing his work at OpenBiome a few weeks ago. All those microbes in our intestines seem destined to play an important role in the future of medical care. Right now, fecal transplants are used against Clostridium difficile infection. Dr. Kassam kindly agreed to chat with us and describe where he thinks the field of microbiome-based therapy is headed. Among the research under way, he describes one project on ulcerative colitis and another on hepatic encephalopathy in which fecal transplants have brought surprising results. He recommended two books during our interview, and I’ve linked to their slots on Amazon’s bookshelves below: Missing Microbes by Martin Blaser Let Them Eat Dirt by  B. Brett Finlay and Marie-Claire Arrieta Clinical Conversations comes to you through the NEJM Group. Executive producer, Kristin Kelley. The post Podcast 207: Fecal transplants, the gut microbiome and future medical care fi

All previous editions are available at podcasts.jwatch.org. Have you prepared a dinner party recently and not heard the word “gluten” come up? Using food-frequency questionnaires, researchers followed the dietary habits of two very large cohorts of clinicians for over 25 years. Their results, just published in The BMJ suggest that, unless you have celiac disease or gluten sensitivity, you’re better off not avoiding the stuff. Our conversation is with the senior author, Andrew T. Chan. Clinical Conversations comes to you through the NEJM Group. Executive producer, Kristin Kelley. Next week: We visit with the chief medical officer of OpenBiome. The post Podcast 206: Gluten avoidance and cardiac risks first appeared on Clinical Conversations.

Danielle Ofri has written a new book, “What Patients Say, What Doctors Hear,” that’s full of advice on how best to listen to your patients. She also recounts her own adventures (and misadventures) in patient communication. The book is published by Beacon Press, which offers a free first chapter available for immediate electronic reading. Details are on Dr. Ofri’s site. [Running time: 15 minutes] The post Podcast 205: Listen to the patient! first appeared on Clinical Conversations.

[Note: a transcript of this interview will be added in a few days’ time.] Our guest has strong indirect evidence that medical marijuana has been replacing “standard” drugs in states where it is legal. In doing so, the substitution is saving the Medicare system modest amounts of money. Their evidence, published in Health Affairs, comes from an examination of national Medicare Part D records over a 4-year span. Health Affairs study (free abstract) Physician’s First Watch coverage (free) The post Podcast 204: Medical marijuana’s effect on Medicare prescriptions first appeared on Clinical Conversations.

Download the TRANSCRIPTION_JWPodcast203 We talk with Dr. Margaret McCartney of Glasgow about her essay in The BMJ. She and her three co-authors titled it “Making Evidence-Based Medicine Work for Individual Patients.” Note: We’re going to start including transcripts, and may even add transcripts to earlier podcasts. Let me know your reactions at jelia@nejm.org. BMJ essay Transcript of Podcast 203 Guest: Dr. Margaret McCartney June 2016 JOE ELIA:  You’re listening to Clinical Conversations. I’m Joe Elia. Our guest this time is Dr. Margaret McCartney a Glasgow-based general practitioner and author. She, along with three others, wrote an essay for the BMJ in mid-May entitled “Making Evidence-Based Medicine Work for Individual Patients.” [http://www.bmj.com/content/353/bmj.i2452] The essay points out a few things about the guidelines that come from the evidence-based approach. Among the observations is that guidelines too often discount the patient’s role in decision-making. There are other observations, and we

Drs. Kristi Koenig and Carl Schultz have just published a second edition of their textbook Disaster Medicine: Comprehensive principles and practices. And they do mean comprehensive. The book runs some 750 pages, covering everything from ethics (not so different from “normal” ethics, it turns out) to managing mass gatherings (a nice guide is provided), tornadoes, volcanoes, and all the rest of the things that take societies unaware. Here’s a link to the book on Amazon. The post Podcast 202: Disaster Medicine — a New Edition first appeared on Clinical Conversations.