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 Conversations.

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.