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A conversation with Dr. Ira Casson (who served on the National Football League’s committee on mild traumatic brain injury and co-authored several of its studies on MTBI) reveals that it may be impossible to assess the value of its six-season study. Despite the author’s defense of the methods used to conduct the research, there’s room for skepticism, both in the light of a New York Times story reporting that over 10% of such injuries may have gone unreported and the study’s assumption that all teams reported all injuries. We asked the League to make the studies’ first author available for this conversation, and they declined. The post Podcast 201: The NFL’s concussion-research flaws first appeared on Clinical Conversations.

Most of the time, pathologists agree with each other about breast biopsy results — especially when the biopsy is negative or indicates invasive cancer. However, the biopsies that fall between those two extremes — that is, atypia and ductal carcinoma in situ — make for tough conversations with patients. This week’s guest, Alexander Borowsky, has written an editorial (with Laura Esserman) about the problem, and he offers advice to clinicians about conveying diagnostic uncertainty. Their editorial also calls into question the words used to describe breast biopsy results, pointing out that a report of “ductal carcinoma” in situ has a way of making people reach for their scalpels — not always wisely. The editorial accompanies a study in the Annals of Internal Medicine that examines precision of biopsy diagnoses. (One aspect of the editorial we never got to discuss in the podcast was its citation of “Car Talk,” on the question how uncertainties feed into each other. That’s worth a link, given below.) Annals of Inte

There’s change in the air about science publishing, and Harlan Krumholz, the founding editor of the journal Circulation: Cardiovascular Quality and Outcomes, thinks it’s time to reimagine the whole concept of what a journal is and what it does. He poured his ideas into an editorial, “The End of Journals,” which he published as he approached the end of his editorship. We finally caught up with him weeks later (he’s elusive) and talked about those ideas. (As this podcast was being readied for posting, the New York Times published an account of Nobel laureate Carol Greider’s posting of work on bioRxiv. She celebrated by tweeting under #ASAPbio.) The post Podcast 199: Rethinking what medical journals do first appeared on Clinical Conversations.

M-16 and candle, 1968 Implementing universal background checks for gun purchases, for ammunition purchases, and mandating firearm identification could dramatically lower U.S. mortality attributable to firearms, our guest says. In the Lancet, Dr. Bindu Kalesan and her colleagues examined state gun laws associated with the lowest mortality rates and concluded that if three of those laws were implemented at the national level, rates would drop by over 90%. Lancet article (free abstract) The post Podcast 198: Three laws that could reduce U.S. firearm mortality first appeared on Clinical Conversations.

The authors of the new sepsis definitions encouraged “debate and discussion,” and an editorial in Chest was quick to provide it. The editorialist, Dr. Steven Simpson, is worried about missing some cases if consideration of SIRS (the systemic inflammatory response syndrome) is tossed out of the definition. Chest editorial (free PDF available if you scroll down that landing page) Last week’s interview on the new defintions (free) The post Podcast 197: A dissent on sepsis first appeared on Clinical Conversations.

We have Edward Abraham, Dean of Wake Forest School of Medicine, with us to talk about the new definitions of sepsis and septic shock. He wrote an editorial in JAMA that puts the changed definitions into perspective for clinicians. Listen in. Editorial in JAMA (free) JAMA paper with new definitions (free) NEJM Journal Watch coverage (free) The post Podcast 196: Sepsis redefined first appeared on Clinical Conversations.

Pioglitazone, long known to increase insulin sensitivity, has been “mostly relegated to use in unusual conditions such as lipodystrophies” after its drug class, the thiazolidinediones, “fell from grace” in the words of our guest. Dr. Clay Semenkovich has just written an editorial comment on a study in the New England Journal of Medicine. That study showed a benefit from pioglitazone use in the secondary prevention of vascular events among patients with insulin resistance (but not diabetes) who’d had a recent ischemic stroke or TIA. He discusses the implications of those findings and, given the drug’s side effects, cautions against a rush to prescribing pioglitazone without first discussing the trade-offs with patients. NEJM editorial (free) NEJM study (free) Physician’s First Watch coverage (free) The post Podcast 195: Pioglitazone for secondary prevention? first appeared on Clinical Conversations.

Ever since Anne Case and Angus Deaton published a paper in the Proceedings of the National Academy of Sciences last November there has been a spate of commentary over their major finding: mortality rates among middle-aged whites in the U.S. are rising while everyone else’s are improving. The Commonwealth Fund has just published an “issue brief” on the topic, and we’ve got the authors — senior researcher David Squires and Fund president David Blumenthal — to talk things over with us. Commonwealth Fund issue brief (free) PNAS study (free) The post Podcast 194: Rising middle-age mortality rates are worrying first appeared on Clinical Conversations.

We usually don’t venture into oncology here, but the approach taken to glioma treatment in a JAMA paper — maintenance therapy with chemotherapy plus alternating electrical fields delivered transdermally via transducers — seems worth reporting to all clinicians. It prolonged patients’ lives significantly, which, according to an editorialist, hasn’t occurred in this disease in at least a decade. The first-author of the manufacturer-sponsored research, Dr. Roger Stupp, explains the approach and the implications it holds for patients with this rapidly progressing tumor. Physician’s First Watch coverage (free) JAMA paper (free) JAMA editorial (subscription required) The post Podcast 193: Glioma survival lengthened first appeared on Clinical Conversations.

Over half the patients with Type 2 diabetes have their HbA1c measured too frequently — i.e., at least three times a year. Why is that a bad thing? Dr. Rozalina McCoy, the lead author of a paper in The BMJ explains. Using claims data, her group followed over 30,000 patients with stable HbA1c levels and found that only 40% had measurements taken within guideline-suggested limits — twice a year. Links: BMJ study on overtesting of HbA1c Physician’s First Watch coverage of BMJ study A November 2015 interview on treatment “deintensification” (free) The post Podcast 192: Are we too sweet on HbA1c testing? first appeared on Clinical Conversations.

[Running time: 13 minutes] The 2008 and 2012 recommendations from the USPSTF regarding PSA-based prostate screening have been accompanied by drops in both the screening and detection rates of prostate cancer, two studies in JAMA find. Our guest, Dr. David Penson, wrote an editorial accompanying those studies. It attempts to put these new findings into perspective and to help the patients and physicians caught in the middle of a continuing debate on the wisdom of screening. Physician’s First Watch coverage of the JAMA studies and editorial (free) The post Podcast 191: The prostate screening conundrum first appeared on Clinical Conversations.

The Lancet Infectious Diseases has just published a worrying account from China about a dangerous antibiotic resistance factor carried on plasmids. The factor, called MCR-1, confers resistance to colistin — a last line of defense against multi-resistant Gram-negative bacilli. The co-author of a helpful commentary in that journal, Dr. David L. Paterson of the University of Queensland in Brisbane, is our guest. Lancet Infectious Diseases article (free abstract) Lancet Infectious Diseases commentary (free abstract) Physician’s First Watch coverage (free) The post Podcast 190: Last line of antibiotic defense breached first appeared on Clinical Conversations.

The SPRINT study, suggesting that we aim for a systolic BP target of 120 mm Hg in high-risk hypertensive patients, has been published with much fanfare. Dr. Paul Whelton — one of the SPRINT investigators — is our guest. He warns against setting 120 as a performance measure, observing that roughly half the patients in the aggressively treated group had levels above that. Links: NEJM article (free) The post Podcast 189: Blood Pressure Target Should Be 120, SPRINT Data Show first appeared on Clinical Conversations.

The ACCORD trial found dangers in too-strict control of blood pressure and glucose in diabetes. Our guest has just published a study in JAMA Internal Medicine measuring the scope of the problem. Using Veterans Affairs data, his group found that “deintensification” of therapy after targets were met or exceeded was disappointingly rare. JAMA Internal Medicine study (free abstract) Physician’s First Watch summary (free) The post Podcast 188: Should “deintensification” be a quality-of-care measure? first appeared on Clinical Conversations.

We interview John Baron about his recent New England Journal of Medicine study testing the ability of calcium or vitamin D (or both) to prevent recurrences of colorectal adenomas in a population who had lesions found during colonoscopy. On follow-up after three to five years, the effects of daily calcium and/or vitamin D supplements were the same as for placebo — that is, there was no significant reduction in risk. The results were surprising, since the same author found a protective effect for calcium in a 1999 publication in NEJM. (In that study, vitamin D wasn’t tested.) LINKS: New England Journal of Medicine study (free abstract) Physician’s First Watch coverage (free) The post Podcast 187: Colorectal adenomas not prevented by calcium and/or vitamin D first appeared on Clinical Conversations.

Two analyses in the BMJ show little or no benefit from loading up older patients with calcium — indeed, the bad side effects of doing so (kidney stones and cardiovascular problems, to name two) outweigh the benefits. Our conversation with Dr. Mark Bolland should offer reassurance to clinicians and their patients that a normal diet will provide enough of the stuff for good health. BMJ studies (free) Fracture risk Bone mineral density Physician’s First Watch coverage (free) [Running time: 18 minutes] The post Podcast 186: Stop supplementing calcium! first appeared on Clinical Conversations.

A group of physicians, economists, and medical students gathered on Medstro to talk about Medicare’s solution to the decades-old “doc fix” problem — it’s how you get paid for caring for Medicare patients. The chat was occasioned by an essay in the New England Journal of Medicine by Meredith Rosenthal, an economist and a close observer of Medicare policy and reimbursement in general. She joins the discussion and helps sort things out. You’ll want to listen, but we warn you: it’s contentious! [Running time: 29 minutes] NEJM essay (free) The post Podcast 185: A Spirited Discussion on Medicare’s ‘Doc Fix’ Fix for Reimbursement first appeared on Clinical Conversations.

Pulmonary embolism is a vexing problem in primary care: Does this patient have it? Can I send them home with reassurance? Should I refer them for further testing? A Dutch group has evaluated the tests most likely to be available in the primary care setting — the various flavors of the Wells rules and the Geneva scores — against a panel of some 600 patients with suspected PE and known outcomes after referral and three months’ follow-up. They come down in favor of the Wells rule and simple D-dimer testing, but an editorialist in the BMJ offers a note of dissent. Our interview with one of the study authors, Dr. Geert-Jan Geersing, sorts this all out. [Running time: 13 minutes] BMJ study (free) BMJ editorial (subscription required) The post Podcast 184: Ruling out pulmonary embolism in primary care first appeared on Clinical Conversations.

There’s a kind of “wall switch” in the human genome that’s been newly described. It seems to be able to turn on and off genes controlling the efficiency with which we burn fat. The study describing the finding in the New England Journal of Medicine reads like a genetic research tour-de-force, showing how the whole circuit is controlled by a single variation in a nucleotide sequence. The study’s senior author, MIT’s Manolis Kellis, examines the switch and its implications. [running time: 26 minutes] NEJM study (free) NEJM editorial (free) Physician’s First Watch coverage The post Podcast 183: An Obesity ‘Switch’ in the Genome Described first appeared on Clinical Conversations.

The BMJ’s meta-analysis of several large cohorts finds no association of saturated fat with all-cause and cardiovascular mortality or total coronary disease. Trans fat, on the other hand, increased risk in all those categories. The first author on the paper, Dr. Russell de Sousza, isn’t ready to give a free pass to saturated fat, though. Listen in as he explains. BMJ meta-analysis (free) Physician’s First Watch coverage (free) [Running time: 19 minutes] The post Podcast 182: Dietary fat studies meta-analyzed — trans fat still a bad bet first appeared on Clinical Conversations.