Clinical Conversations

Influenza A (H3N2)v — a novel flu virus that emerged last summer and shows signs of being able to transmit itself from person to person — is our topic this week.
The virus carries genes from swine and avian flu viruses, and the few cases found in the U.S. all made complete recovery.
We talk with CDC epidemiologists involved in assessing the threat, and they’re reassuring on two fronts: first of all, most of the population shows at least some cross-reactive antibody to the virus; and second, they’ve isolated a candidate vaccine virus that they would use in the event that A (H3N2)v started showing increased ability for person-to-person transmission.
Links:
MMWR article on influenza A (H3N2)v antibodies (free)
CDC advice on treating influenza A (H3N2)v (free)
Physician’s First Watch coverage (free)
The post Podcast 151: Most people above age 10 have at least some cross-reactive antibodies to variant influenza first appeared on Clinical Conversations.

After stroke or transient ischemic attack, depression is more common than among the general population, and the risk for depression extends beyond the early time period after the event.
More alarmingly, less than a third of those with persistent depression — defined as depression detected both at 3 and 12 months after the cerebrovascular event — receive antidepressant medication.
We offer an interview with Dr. Nada El Husseini, first author of a study published online in Stroke that presents the data supporting those observations.
Link:
Stroke abstract (free)
Physician’s First Watch summary (free)
The post Podcast 150: Depression (and antidepressant use) after stroke or TIA first appeared on Clinical Conversations.

A BMJ meta-analysis suggests that people with the highest levels of white rice consumption are at increased risk for type 2 diabetes.
The authors examined four studies, together comprising some 350,000 subjects. Two were done in Asian populations and two among Westerners. They found a much higher intake of white rice among Asians, and a strong association between consumption level and risk. In Western populations, the association was suggestive, but not as strong.
The effect may possibly derive from the higher glycemic load with increasing consumption, or from the nutrients stripped away with the rice husk during milling.
The senior author, Dr. Qi Sun, discusses his findings with us in a brief interview.
Links:
BMJ article (free)
The post Podcast 149: High levels of white rice consumption seem linked to higher risks for type 2 diabetes first appeared on Clinical Conversations.

In the largest study of its kind, UK researchers find that helping pregnant women to quit smoking until at least delivery isn’t helped much by nicotine replacement therapy.
The primary outcome, self-reported cessation lasting between the start of therapy and delivery, differed little between the active treatment group and those randomized to placebo (9% versus 8%).
In addition, compliance was low in both groups.
Links
New England Journal of Medicine abstract (free)
The post Podcast 148: Smoking cessation during pregnancy is probably more effective with behavioral approaches than with relying on nicotine replacement first appeared on Clinical Conversations.

Everyone “knows” that colonoscopy reduces risks of death from colorectal cancer, but it’s good to have your knowledge actually verified, and a new bit of research seems to do that in this case.
Long-term follow-up of a group of patients who underwent colonoscopy and polypectomy in the 1980s shows that removal of adenomatous polyps brought with it a risk of dying from colorectal that was half the risk found in the general population. About 80% of these patients, it should be mentioned, underwent strict surveillance for 10 years after their adenomatous polyps were excised.
This is good news, no? And it offers clinicians a “teaching moment” with their patients who are reluctant to undergo the procedure.
Listen in as we interview Dr. Ann Zauber, first author on the New England Journal of Medicine paper.
Links:
Physician’s First Watch coverage of the research (free)
New England Journal of Medicine abstract (free)
New England Journal of Medicine editorial (subscription required)
The post Podcast 147: Proof that colonoscopy with polypectomy saves lives first appeared on Clinical Conversations.

Current guidelines find no compelling therapeutic benefit to screening for cognitive impairment and dementia in primary care. The Journal of the American Geriatrics Society has published some research that, if not compelling, certainly suggests that clinical approaches should change.
In actively screening some 8000 veterans over age 70 during routine primary care visits for cognitive impairment, researchers found a quarter to have signs suggesting further investigation was needed. When all was said and done, 11% had cognitive impairment; that’s two to three times the rate found in settings where physicians waited for impairment to manifest itself clinically.
We interview the lead author, who offers reasons why he thinks simple screening should be routine in elderly populations, despite the current absence of treatments for mild cognitive impairment and dementia.
Links:
Physician’s First Watch coverage (free)
Journal of the American Geriatrics Society abstract (free)
USPSTF current screening guidelines (free)
Mini-Cog screening test (free)
The post Podcast 146: Cognitive impairment in primary care — screen or not? first appeared on Clinical Conversations.

Haplogroups — who knew? Ancient variations in the Y chromosome form what’s known as haplogroups, and haplogroup I is common in Europe, particularly so in northern Europe. Researchers find that “I” is an independent risk factor for coronary artery disease in men, carried as it is on the male-only Y chromosome.
Listen in as we talk ancient genetics and what it all could mean for a range of immune-system-related diseases. There’s plenty of work to be done, but we thought you ought to know about this earlier rather than later.
Links:
Physician’s First Watch coverage (free)
Lancet abstract (free)
The post Podcast 145: The Y chromosome and the possible role of a common variant in coronary disease in men. first appeared on Clinical Conversations.

PPIs are back on our radar, and this time it’s their regular use among postmenopausal women.
A BMJ article examines data from the Nurses’ Health Study to show a significantly increased risk for hip fracture among postmenopausal women with any smoking history. Never-smokers showed no statistically significant increase.
Now that proton pump inhibitors have been available over-the-counter for the better part of a decade, should clinicians be asking about their patients’ smoking history in concert with asking about how they handle heartburn?
Links:
BMJ article (free)
Physician’s First Watch summary (free)
FDA’s May 2010 warning on PPIs and fracture risks (free)
The post Podcast 144: Hip fractures, PPIs, and smoking history in postmenopausal women — increased risks first appeared on Clinical Conversations.

Controlling asthma by the use of proton pump inhibitors apparently doesn’t work any better in children than it does in adults. Yet the practice is widely used.
A study in JAMA and an accompanying fiery editorial seem to put the notion to rest. Listen in.
As always, suggestions are welcomed. You can reach me directly at 617-440-4374 — don’t be shy!
Links:
JAMA study coverage in Physician’s First Watch (free)
Earlier (2009) Clinical Conversations podcast #38 with Dr. Robert Wise on the effect of PPIs in adult asthma (free)
The post Podcast 143: PPIs and asthma control — it doesn’t work in kids, either first appeared on Clinical Conversations.

The American College of Physicians wants to encourage high-value, cost-conscious care. And so they convened a consensus panel of physicians to list tests that they considered overused or inappropriately used in certain circumstances. One example would be the use of MRI for breast screening in normal-risk patients; another is the use of imaging studies in the diagnosis of nonspecific low-back pain.
The panel came up with about 40 such examples, and the ACP is inviting your reactions (and suggestions for further examples) on a survey available on its website, a link to which is in the list below.
Meanwhile, listen in on a 15-minute conversation with Dr. Amir Qaseem, the first author of the panel’s report, just published in the Annals of Internal Medicine. An editorial on the report cites a Congressional Budget Office study estimating that 5% of the nation’s GDP is misspent on medical tests and procedures that don’t help the patient. That’s fully 25% of all health expenditures! Houston, we have a problem….
Links:
Physician’s First Watch coverage (free)
Annals of Internal Medicine article (free abstract)
ACP survey form (free access)
The post Podcast 142: Really, why are you ordering that test? first appeared on Clinical Conversations.