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.