Clinical Conversations

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 Internal Medicine editorial (subscription required)
Annals study (free abstract)
Car Talk episode (start listening at the 17 min, 45 sec mark)
The post Podcast 200: Sorting out the results of breast biopsy first appeared on Clinical Conversations.

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.