Clinical Conversations

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 atrial fibrillation increases stroke risk; does subclinical afib do the same? first appeared on Clinical Conversations.

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 online first appeared on Clinical Conversations.

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 Clinical Conversations.

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.