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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 post Podcast 141: Clinically apparent at

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) The post Podcast 140: A new edition of the ACP’s manual on ethics for clinicians is available

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) The post Podcast 139: CPAP for obstructive sleep apnea seems to improve some measures of the metabolic syndrome first appeared on Clinical Conversations.

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) The post Podcast 138: Why do kids in the U.S. get so many inappropriate broad-spectrum antibiotics? first appeared on Clinical Conversations.

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 The post Podcast 137: Clamping the umbilical cord — what’s the big rush? first appeared on Clinical Conversations.

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 post Podcast 136: Aspirin lowers colorectal risks in Lynch syndrome — what are the implications for everyone else? first appeared on Clinical Conversations.

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) The post Podcast 135: HPV vaccine effective against anal intraepithelial neoplasia in MSM. Now, how to get it to young men before they’re sexually active? first appeared on Clinical Conversations.

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 The post Podcast 134: How (and why) surveillance in Barrett’s esophagus should change first appeared on Clinical Conversations.

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) The post Podcast 133: Over 50 years later, DES’s adverse effects continue first appeared on Clinica

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) The post Podcast 132: In discussing a child’s overweight with parents, words matter first appeared on Clinical Conversations.

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) The post Podcast 131: Measuring the effect of the rotavirus vaccine program on kids in the U.S. first appeared on Clinical Conversations.

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) The post Podcast 130: If you’re a clinician concerned about health costs, wash your hands — don’t just wring them first appeared on Clinical Conversations.

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) The post Podcast 129: Non-aspirin NSAIDs are associated, as a class, with spontaneous abortion in a Quebec study first appeared on Clinical Conversations.

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) The post Podcast 128: Bleeding patients, inadvertently, into anemia happens more often than you might think first appeared on Clinical Conversations.

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) The post Podcast 127: Why QALYs matter first appeared on Clinical Conversations.

Last week’s New England Journal of Medicine paper on the placebo effect in evaluating asthma treatments was fascinating in itself. The editorial that accompanied it, however, was a delight. It asks clinicians to think less about laboratory measures of cure, and more about the patient’s satisfaction with treatment — whether the treatment was “real” or not. This week’s guest, Dr. Daniel Moerman, wrote that editorial. His training in anthropology adds a refreshing viewpoint to his observations on clinical medicine. Let us know what you think by leaving a comment. Relevant links: Physician’s First Watch coverage of the NEJM paper Two acupuncture papers mentioned by Moerman in his interview (and cited in his editorial): Cherkin et al. Haake et al. Franz Ingelfinger’s essay, “Arrogance” Moerman & Jonas paper from Annals of Internal Medicine The post Podcast 126: Placebos and Medical ‘Meaning’ first appeared on Clinical Conversations.

There is a new meta-analysis from the Canadian Medical Association Journal that finds increased risks among smokers trying to quit and taking varenicline (Chantix). Among smokers with stable cardiovascular disease, the number needed to treat to cause an adverse cardiovascular event is about 30, yet the number needed to treat to achieve smoking cessation is 10. Our guest, Dr. Sonal Singh, is the first author of this meta-analysis. As you’ll hear, he has strong feelings about his team’s findings. Related links: CMAJ paper (free) CMAJ commentary (sorry, but it’s not free) Physician’s First Watch coverage of the paper (free) The post Podcast 125: The smoking-cessation drug varenicline poses some difficult tradeoffs. first appeared on Clinical Conversations.

Patients’ systolic pressures vary by about 10%, regardless of whether they are measured at home or under the duress of a visit to the doctor. That variation is troubling when deciding whether to put a patient on an antihypertensive regimen: how reliable are the measurements that will form the basis of your decision? How do you get the data you need to really make an informed decision? This edition of Clinical Conversations is all about those questions. It’s with the first author of a June 23 Annals of Internal Medicine paper that reports a striking variation, not only among measurements made with highly calibrated machines, but also between measurements made in the clinic, at home, or — most carefully — in research settings. We hope you’ll enjoy listening in and that you’ll leave some comments with us. Related link: Annals of Internal Medicine article (free) Physician’s First Watch coverage (free) The post Podcast 124: Getting more accuracy into blood pressure measurements first appeared on Clinical Conversa

On the basis of evidence from a Swedish cohort, calcium intakes much above that country’s recommended 800 mg daily don’t have added protective value against fracture and osteoporosis. The authors of this BMJ paper suggest we’d be better off making sure those at the low end of the calcium-intake spectrum get their 800 mg, rather than trying to overinsure “protection” with too much of the stuff. We have an interview with first-author Eva Warensjö. Links: BMJ article (free) Physician’s First Watch coverage (free) The post Podcast 123: Calcium’s benefits seem to peak out at about 800 mg daily first appeared on Clinical Conversations.

A paper from Denmark looks at five newer-generation antiepileptics and finds no strong birth-defects signal associated with their use in the first trimester. However, as the senior author points out in a statement to Clinical Conversations, one of the drugs — topiramate — has only recently been cited by the FDA as carrying a risk for cleft lip and palate, and the JAMA study did not look specifically for that complication. Dr. Danielle Scheurer and Joe Elia talk about the study and read the author’s statement, sent via email (the authors — epidemiologists — respectfully declined an interview regarding clinical matters). Links: Abstract of the JAMA study (free) FDA MedWatch warning on topiramate (free) U.K. study of 200 cases of topiramate exposure in Neurology (free abstract) FDA statement on topiramate as Pregnancy Category D (free) The post Podcast 122: Most newer antiepileptics apparently safer in early pregnancy — but not all. first appeared on Clinical Conversations.