Clinical Conversations

Intermittent fasting has salutary effects. Listen how Dr. Mark P. Mattson, co-author of a recent NEJM review on the topic, assesses the practice — and how he’s managed to skip breakfast for the past 30 years or so.
Dr. Ali Raja joins Joe as co-host again this time.
Links:
de Cabo and Mattson’s review in the New England Journal of Medicine
Michael Mosley and Mimi Spencer’s book “The FastDiet”
Running time: 18 minutes
The post Podcast 251: Intermittent fasting first appeared on Clinical Conversations.

It turns out that the disrespect starts even earlier — when women are questioned about their choice of a surgical specialty. Nor is the bad behavior the exclusive province of the “old guard.”
We talk with Dr. Pringl Miller, a Chicago surgeon who’s compiled a collection of instructive stories from women surgeons who’ve had to dodge demeaning questions (and sometimes, flying chairs in the OR). The stories appear in the latest issue of Narrative Inquiry in Bioethics.
“#MeToo in Surgery: Narratives by Women Surgeons” article in Narrative Inquiry in Bioethics
Recent NEJM article on harassment in surgical residency training
Time’s Up Healthcare website
Patricia Dawson’s book: “Forged by the Knife: The experience of surgical residency from the perspective of a woman of color”
Preeti John’s book: “Being a Woman Surgeon: Sixty women share their stories”
Joan Cassell’s book: “The Woman in the Surgeon’s Body”
Running time: 18 minutes
The post Podcast 250: #MeToo in the OR first appeared on Clinical Conversations.

Why aren’t you able to navigate your electronic health record (EHR) as easily as you can find a recipe on, say, Google?
And, what about those requirements for documenting everything?
Listen to a chat with Julia Adler-Milstein, the author of an editorial that comments on a recent Annals of Internal Medicine study detailing the amount of time clinicians typically spend hunched over their EHRs during a patient visit.
Links:
Annals of Internal Medicine editorial
Annals paper on the time clinicians spend
Running time: 17 minutes
The post Podcast 249: Quality time with your EHR — or just time? first appeared on Clinical Conversations.

The process of identifying super-users of healthcare and reducing the frequency of their hospitalizations — so-called “hotspotting” — was subjected to a randomized, controlled trial in Camden, NJ, the birthplace of the idea. It failed there.
Those in the intervention group had a readmission rate within 6 months that was statistically identical to those getting usual care.
True, the Camden patients had particularly complex social and medical problems, so that doesn’t mean that the program can’t work elsewhere.
Listen to our chat with the report’s senior author, Prof. Joseph Doyle, and as well, listen to our interview with Dr. Jeffrey Brenner from 6 years ago — he’s the one who put “hotspotting” on the map. Despite the apparent failure of the trial, the Coalition still has a lot to offer.
Results of the randomized trial in NEJM
Interview with Dr. Jeffrey Brenner from 2013
Camden Coalition’s website
Running time: 15 minutes
The post Podcast 248: “Hotspotting” didn’t work in its home town — why? first appeared on Clinical Conversations.

A “network meta-analysis” (we’ll explain that) finds that “test and treat” is the best way forward in managing this common condition.
Patients, paradoxically, prefer immediate endoscopy to test-and-treat, but unless the patient has “alarm symptoms” (such as dysphagia, weight loss, and anemia), endoscopy is likely to add complications and costs without adding further benefit.
Our guest is Prof. Alexander Ford of Leeds, senior author on the guideline-affirming study in The BMJ.
Links:
Article in The BMJ
Physician’s First Watch summary
NEJM Journal Watch Gastroenterology summary of 2017 joint U.S. – Canadian guideline
The post Podcast 247: Managing dyspepsia first appeared on Clinical Conversations.

For the first time in almost a century, Americans are dying at home more often than dying in hospitals.
This seems to mark a cultural change that will affect both how and where clinical medicine is practiced.
Dr. Haider Warraich’s letter to the editor of the NEJM presents the numbers, and he’s agreed to talk about their implications.
Links:
Cross and Warraich’s New England Journal of Medicine letter (Dec. 12 issue)
Warraich’s 2017 book “Modern Death”
“Near Death,” a Frederick Wiseman 6-hour documentary worth finding
Running time: 16 minutes
The post Podcast 246: Where we die now first appeared on Clinical Conversations.

In November 2018 we interviewed two authors of an Annals of Internal Medicine study comparing the quality of diabetes care afforded by three provider types: nurse-practitioners, PAs, and MDs. They reported that there were no clinically significant differences in the intermediate outcomes — glycated hemoglobin, systolic pressure, or low-density lipoprotein cholesterol — among the groups.
We’re posting that interview again for two reasons: first, this week’s planned interviewee remained unreachable, no matter my pleadings; second, listeners reacted strongly (and positively)  the first time around, and I hope newer listeners will find it as interesting.
Links:
URL of the original podcast
Annals of Internal Medicine paper
Running time: 20 minutes
The post Podcast 245: We revisit a 2018 episode on NPs’, PAs’, and MDs’ performance in the primary care of diabetes first appeared on Clinical Conversations.

The anti-inflammatory colchicine is powerful and cheap. It’s thought that, because cardiovascular problems often stem from inflammation, colchicine could help prevent secondary events after MI. That’s what Jean-Claude Tardif and an international group of colleagues set out to investigate.
The group reports in the NEJM that daily low-dose colchicine was associated with a lower rate of a composite endpoint than a placebo: death from cadiovascular causes, resuscitated cardiac arrest, MI, stroke, or urgent hospitalization leading to coronary revascularization.
New England Journal of Medicine report
Editorial commentary in NEJM
Harlan Krumholz’s tweet on the report
Running time: 20 minutes
The post Podcast 244: Colchicine after myocardial infarction first appeared on Clinical Conversations.

Controlling hypertension lowers the relative risk for dementia and Alzheimer’s disease by roughly 15%.
Given that many people have poorly-controlled hypertension, the finding that all antihypertensives are effective in bringing about this result might get your patients to be more adherent.
We talk with Dr. Lenore Launer of the NIH’s Institute on Aging about her recent meta-analysis in The Lancet Neurology.
LINKS:
Launer’s paper in The Lancet Neurology
Lancet comment on the article
Running time: 16 minutes
The post Podcast 243: Lowering high blood pressure lowers dementia risk first appeared on Clinical Conversations.

Tranexamic acid, which frustrates clot dissolution, has been shown to reduce death from intracranial bleeding in a large international placebo-controlled trial — “CRASH-3.”
Ali Raja and Joe Elia host a lively chat with Ian Roberts, the co-chair of the trial’s writing committee, who, in addition to chastising the hosts’ seeming fascination with P-values, recounts a story from early in his training that first stirred his devotion to preventing bleeding-related death after trauma.
NEJM Journal Watch Emergency Medicine summary of CRASH-3
CRASH-3 report in The Lancet
Ian Roberts explains CRASH-3 on YouTube to collaborators in Malaysia
Roberts presents CRASH-3 results at World Congress on Intensive Care on YouTube
Running time: 23 minutes
The post Podcast 242: Tranexamic acid saves lives after traumatic bleeds first appeared on Clinical Conversations.