A VIDEO RECORDING OF THIS INTERVIEW IS AVAILABLE HERE.

This time, we look to New York for guidance on recognizing and treating monkeypox.

Dr. Eric Meyerowitz of Montefiore and Dr. Stephen Baum of Einstein will lead you through the monkeypox thicket in a 17-minute chat.

Included below is information for patients as well as links to some key articles of interest to clinicians.

LINKS:

For patients: Dr. Barry Zingman’s “Monkeypox — What you need to know”

For clinicians:

• NEJM article on monkeypox in 16 countries
• NEJM Case Records of the Mass. General Hospital on the state’s first case
• Stephen Baum’s summary of a paper in Emerging Infectious Diseases describing viral persistence on fomites

A VIDEO RECORDING OF THIS INTERVIEW IS AVAILABLE HERE.

We’re back with another interview from this year’s IASLC conference.

This time, Christine Sadlowski and Dr. Julia Rotow interview Dr. Mariano Provencio about the survival outcomes from the NADIM II trial. In that trial, patients with resectable stage III AB non-small cell lung cancer received nivolumab plus chemotherapy versus chemotherapy alone.

Overall survival at 5 years in these patients has been roughly 30%, according to Provencio. With the addition of chemo-immunotherapy, patients who showed a complete pathological response were all alive at the 3-year mark. These results, according to Rotow, are “really quite exciting.”

INTERVIEW TRANSCRIPT

Christine Sadlowski:

This is part of the NEJM Group coverage of the IASLC’s 2022 World Conference on Lung Cancer. I’m Christine Sadlowski, and with me Dr. Julia Rotow, a clinical oncologist at Dana-Farber Cancer Institute in Boston. We’re here to interview Dr. Mariano Provencio, Chair of Medical Oncology at the Hospital Universitario Puerta de Hierro Majadahonda in Madrid in Spain. He is the lead author on NADIM II, a phase 2 trial of neoadjuvant nivolumab added to chemotherapy for resectable stage III AB non-small cell lung cancer. Welcome.

Dr. Mariano Provencio:

Thank you.

Christine Sadlowski:

So first, I’d like to ask you about the history of this research because these findings come after several previous studies, including NADIM nivolumab in this clinical setting. Can you refresh us briefly on what is known so far?

Dr. Mariano Provencio:

We studied the combination with nivolumab plus chemotherapy in NADIM I. It was a clinical trial focused on stage IIIA according to the 7th edition. It was a phase two trial. We obtained very exciting results: in overall survival, three times the historical series; in DFS [disease-free survival] around 77 percent at two years — almost double the historical series — and also early results in PCR, pathological complete response, almost 60 percent.

Then following that was the second clinical trial comparing nivolumab plus chemotherapy versus chemotherapy, and this is NADIM II.

Dr. Julia Rotow:

Thank you, Dr. Provencio. So, when you think about what we knew already in the field, could you take us through some of the key findings from the NADIM II study and what these might add to our current understanding of nivolumab in this setting?

Dr. Mariano Provencio:

In NADIM II, the primary objective was complete pathological response, and we obtained higher complete pathological response in the experimental arm. Nivo plus chemo versus chemo: Odds Ratio 7.88; p = 0.0068. We presented at the last lung cancer congress (IASLC) more progress, in PFS longer with hazard ratio of 0.48 and more overall survival hazard ratio of 0.40. And this is quite amazing results, in my opinion, comparing with chemotherapy arm.

Christine Sadlowski:

Can I go back a little bit and say in this particular presentation you’re showing primarily secondary outcomes, is that correct?

Dr. Mariano Provencio:

We presented the primary end point was a complete pathological response. It was positive and then we presented in this congress the secondary outcomes, survival outcomes, yes.

Christine Sadlowski:

And they were at 12 and 24 months, correct?

Dr. Mariano Provencio:

Correct.

Christine Sadlowski:

I was struck by the finding on overall survival. That’s obviously improved with adjuvant therapy.

Dr. Mariano Provencio:

We use adjuvant nivolumab therapy for six months. We think so, this is the first clinical trials who reported an increase in overall survival in this setting using immunotherapy plus chemotherapy and adjuvant.

Dr. Julia Rotow:

I was struck by these results. They were quite impressive. Are there any caveats we should take away from your status as secondary versus primary outcomes on the study?

Dr. Mariano Provencio:

In the first clinical trial, in NADIM I, the primary endpoint was progression-free survival. We saw pathological complete response was quite robust endpoint. I think these results are very significant in survival outcomes are very, very significant.

Christine Sadlowski:

So, what does that mean for clinical practice? I don’t actually know how nivolumab is currently used. I understand it’s approved for other cancers, not this one, but is it currently used?

Dr. Mariano Provencio:

Currently, we are using a chemo and then certainly in some cases immunotherapy, this subgroup of patients in stages 3A-B (N2) disease have poor prognostic and based on our results we can improve it. We have had the same results during last 30 years using chemotherapy and then these results are quite similar than the CM 816 specifically in stage 3A 3B. In some cases, these patients are considered with unresectable disease, and we obtain very high rate of surgery in these patients, more than 90 percent of patients underwent radical surgery is quite important to the clinical practice, in my opinion.

Our opinion, we should use chemo plus immunotherapy as standard of care in this group of patients as in the adjuvant setting.

Dr. Julia Rotow

You mentioned Checkmate 816, and I know this regimen involves a longer course of immunotherapy because of the adjuvant period. Is there anything that clinicians or patients should know about adverse effects that you saw with this regimen?

Dr. Mariano Provencio:

I think both trials are quite well tolerated results. In CM 816 we don’t use adjuvant therapy. I think maybe we have to have more results, more information about adjuvant period or adjuvant after chemo immunotherapy. Maybe in the future we’ll have to define with more detail this aspect. In any case, I think the most important part is use neoadjuvant chemo immunotherapy.

Dr. Julia Rotow:

I thought that it was great that you highlighted the surgical resection rate because it was quite a bit better with the combination chemo immunotherapy.

Dr. Mariano Provencio:

We have more than 92 percent of surgery. I mentioned before 70 percent of patients had N2 affectation. Half of them, multiple station. This is quite a high rate of radical surgery on more than 92 percent of R0 versus 60 percent in control arm. I think the surgery could be an important aspect to cure these patients.

Christine Sadlowski:

What would you need to do next to show that?

Dr. Mariano Provencio:

The next steps in this case, I think now this is a proof of concept introducing a new treatment in this group of patients. Very important this group of patients. We have almost the same survival within the last 30 years. Around 30 percent of overall survival at five years and no more than 12 or 16 months PFS. I think we have to analyze with more detail clinical trials analyzing pathological response and then in this case adjuvant treatment in these patients according to pathological response.

For example, in our study patients with PCR (complete pathological response) are 100 percent of disease-free and 100% alive at three years.

Dr. Julia Rotow:

Thank you for taking us through. I agree these are really quite exciting results and we’re so happy to have gotten to see them at the conference this year. We certainly look forward to seeing more of this sort of treatment strategy. So, thank you for joining us today.

Dr. Mariano Provencio:

Thank you.

Christine Sadlowski:

Thank you.

In the early waves of the Covid-19 pandemic why did patients in unionized nursing homes, have a roughly 10% lower rate of mortality than those in non-unionized ones? A report in Health Affairs tries to sort out the possible reasons.

Listen to our 13-minute interview, which raises the question: Should you send your patients to non-unionized facilities?

Health Affairs article

A conversation with Dr. Ira Casson (who served on the National Football League’s committee on mild traumatic brain injury and co-authored several of its studies on MTBI) reveals that it may be impossible to assess the value of its six-season study. Despite the author’s defense of the methods used to conduct the research, there’s room for skepticism, both in the light of a New York Times story reporting that over 10% of such injuries may have gone unreported and the study’s assumption that all teams reported all injuries.

We asked the League to make the studies’ first author available for this conversation, and they declined.

Most of the time, pathologists agree with each other about breast biopsy results — especially when the biopsy is negative or indicates invasive cancer. However, the biopsies that fall between those two extremes — that is, atypia and ductal carcinoma in situ — make for tough conversations with patients.

This week’s guest, Alexander Borowsky, has written an editorial (with Laura Esserman) about the problem, and he offers advice to clinicians about conveying diagnostic uncertainty. Their editorial also calls into question the words used to describe breast biopsy results, pointing out that a report of “ductal carcinoma” in situ has a way of making people reach for their scalpels — not always wisely.

The editorial accompanies a study in the Annals of Internal Medicine that examines precision of biopsy diagnoses.

(One aspect of the editorial we never got to discuss in the podcast was its citation of “Car Talk,” on the question how uncertainties feed into each other. That’s worth a link, given below.)

Annals of Internal Medicine editorial (subscription required)

Annals study (free abstract)

Car Talk episode (start listening at the 17 min, 45 sec mark)

There’s change in the air about science publishing, and Harlan Krumholz, the founding editor of the journal Circulation: Cardiovascular Quality and Outcomes, thinks it’s time to reimagine the whole concept of what a journal is and what it does.

He poured his ideas into an editorial, “The End of Journals,” which he published as he approached the end of his editorship. We finally caught up with him weeks later (he’s elusive) and talked about those ideas.

(As this podcast was being readied for posting, the New York Times published an account of Nobel laureate Carol Greider’s posting of work on bioRxiv. She celebrated by tweeting under #ASAPbio.)

M-16 and candle, 1968

Implementing universal background checks for gun purchases, for ammunition purchases, and mandating firearm identification could dramatically lower U.S. mortality attributable to firearms, our guest says.

In the Lancet, Dr. Bindu Kalesan and her colleagues examined state gun laws associated with the lowest mortality rates and concluded that if three of those laws were implemented at the national level, rates would drop by over 90%.

Lancet article (free abstract)

The authors of the new sepsis definitions encouraged “debate and discussion,” and an editorial in Chest was quick to provide it.

The editorialist, Dr. Steven Simpson, is worried about missing some cases if consideration of SIRS (the systemic inflammatory response syndrome) is tossed out of the definition.

Chest editorial (free PDF available if you scroll down that landing page)

Last week’s interview on the new defintions (free)

We have Edward Abraham, Dean of Wake Forest School of Medicine, with us to talk about the new definitions of sepsis and septic shock. He wrote an editorial in JAMA that puts the changed definitions into perspective for clinicians. Listen in.

Editorial in JAMA (free)

JAMA paper with new definitions (free)

NEJM Journal Watch coverage (free)

Pioglitazone, long known to increase insulin sensitivity, has been “mostly relegated to use in unusual conditions such as lipodystrophies” after its drug class, the thiazolidinediones, “fell from grace” in the words of our guest.

Dr. Clay Semenkovich has just written an editorial comment on a study in the New England Journal of Medicine. That study showed a benefit from pioglitazone use in the secondary prevention of vascular events among patients with insulin resistance (but not diabetes) who’d had a recent ischemic stroke or TIA.

He discusses the implications of those findings and, given the drug’s side effects, cautions against a rush to prescribing pioglitazone without first discussing the trade-offs with patients.

NEJM editorial (free)

NEJM study (free)

Physician’s First Watch coverage (free)

Ever since Anne Case and Angus Deaton published a paper in the Proceedings of the National Academy of Sciences last November there has been a spate of commentary over their major finding: mortality rates among middle-aged whites in the U.S. are rising while everyone else’s are improving.

The Commonwealth Fund has just published an “issue brief” on the topic, and we’ve got the authors — senior researcher David Squires and Fund president David Blumenthal — to talk things over with us.

Commonwealth Fund issue brief (free)

PNAS study (free)

We usually don’t venture into oncology here, but the approach taken to glioma treatment in a JAMA paper — maintenance therapy with chemotherapy plus alternating electrical fields delivered transdermally via transducers — seems worth reporting to all clinicians. It prolonged patients’ lives significantly, which, according to an editorialist, hasn’t occurred in this disease in at least a decade.

The first-author of the manufacturer-sponsored research, Dr. Roger Stupp, explains the approach and the implications it holds for patients with this rapidly progressing tumor.

Physician’s First Watch coverage (free)

JAMA paper (free)

JAMA editorial (subscription required)

Over half the patients with Type 2 diabetes have their HbA1c measured too frequently — i.e., at least three times a year. Why is that a bad thing? Dr. Rozalina McCoy, the lead author of a paper in The BMJ explains.

Using claims data, her group followed over 30,000 patients with stable HbA1c levels and found that only 40% had measurements taken within guideline-suggested limits — twice a year.

Links:

• BMJ study on overtesting of HbA1c
• Physician’s First Watch coverage of BMJ study
• A November 2015 interview on treatment “deintensification” (free)

The U.S. Preventive Services Task Force recently issued its sixth set of guidelines on using daily aspirin to prevent cardiovascular disease. The guidelines appeared in JAMA — whose editors asked our guest, Dr. Allan Brett, to write an editorial evaluation.

This edition carries Brett’s advice on using the new guidelines in daily clinical practice.

Brett’s JAMA editorial

USPSTF recommendations in JAMA

[Running time: 15 minutes]

[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 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 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 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)

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)

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]

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)

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)

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 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]

Saline or balanced crystalloids? The question of which resuscitation fluid to use in clinical practice seems to have been settled by recent research findings — or at least settled in favor of balanced crystalloids. But wait, our guests see slight differences that may affect your choice.

Patricia Kritek practices critical care medicine at the University of Washington. In this edition, she pilots a discussion with Todd Rice of Vanderbilt. He has studied the problem carefully, having published two studies in the New England Journal of Medicine in 2018; more recently, he’s written a meta-analysis of the problem in NEJM Evidence.

Listen in on a truly clinical conversation.

[Running time: 16 minutes]

(Running time: 15 minutes)

A study in the Lancet Oncology gathered information from dozens of epidemiological studies to estimate that over 200,000 cases of endometrial cancer have been prevented in the past 10 years as a result of oral contraceptive use.

A commentary in the journal offers a remarkable look at weighing the benefits and harms of OCs. We talk with a co-author of that commentary, Dr. Nicolas Wentzensen of the National Cancer Institute.

Lancet Oncology study

Lancet Oncology comment

How Webster defined it 90 years ago.

The CDC’s Seema Jain is our guest, talking about a study she did with her team to characterize the causes of community-acquired pneumonia in U.S. adults. (They don’t mention finding Webster’s Micrococcus lanceolatus.) Medicine has come a long way since 1925, but Dr. Jain says that clinicians still need better diagnostic tools to pinpoint the causes of CAP in individual patients.

Using five hospitals in Chicago and Nashville, Jain’s team surveyed over 2000 adult patients admitted with radiographic evidence of CAP during a 30-month period. Also included is discussion of her February paper that sought to characterize CAP in children.

NEJM abstract of study in adults

NEJM abstract of study in children

Running time: 20 minutes

The anticoagulant dabigatran, marketed in the U.S. as Pradaxa, has always had the problem that, although it’s more convenient to use, there’s no sure way to stop its effect if the patient has a major bleed.

Now, a monoclonal antibody fragment called idarucizumab (pronounced i-DARE-you-scis-ooh-mab) shows promise as a reversal agent. In an interim analysis of the first 90 of a planned 300 patients, the fragment was quite effective in stopping bleeds.

The analysis was published in the New England Journal of Medicine, and we talk with the paper’s first author, Charles V. Pollack, Jr.

Link to NEJM article (free)

Dr. Scott Allen of Physicians for Human Rights talks about the lessons evident in the complicity of clinicians — physicians, PAs, and psychologists at the very least — in the torture of prisoners.

His group published an analysis under the title “Doing Harm: Health professionals’ central role in the CIA torture program,” and that’s the focus of this discussion. Allen says that the lesson for all clinicians is to remember the importance of their professions’ commitments to patients, which were badly eroded in these episodes.

Running time: 20 minutes

Doing Harm report from PHR

Neel Shah wrote a Perspective essay in the New England Journal of Medicine earlier this month on the U.K.’s NICE recommendation that encourages wider acceptance of home delivery and midwifery. The question is, could it work in the U.S.?

For the audio-oriented Clin Con audience we’ve adapted a video conversation that took place on Medstro (https://medstro.com/groups/nejm-group-open-forum/discussions/112). There, Dr. Shah and other clinicians discuss the problems U.S. obstetricians and U.S. mothers-to-be face. The Medstro forum is now finished, but the discussions back and forth over the course of its 10-day run are still available at the URL above.

Running time: 32 minutes

Running time: 19 minutes

We talk with Dr. Cosette Wheeler about a new Lancet Oncology paper that offers follow-up on two major trials of HPV-16/18 vaccines.

The analysis adds more data to the suspicion that although three doses of vaccine are optimal, two or even one may offer substantial protection. Wheeler is very cautious on this point, however, and insists that the goal must be to deliver three doses to every recipient. In the U.S., HPV vaccine courses are completed less than half the time.

Lancet Oncology abstract

Running time: 26 minutes

“Understanding Value-Based Healthcare,” published in April by McGraw-Hill is today’s focus.

Drs. Christopher Moriates, of the University of California, San Francisco; Vineet Arora, of the University of Chicago; and Neel Shah of Harvard Medical — the book’s authors — discuss its straightforward approach to valuing patient outcomes foremost.

The discussion ranges over their reasons for writing the book, their attempt to reach the broader audience concerned with healthcare costs, and their recommendations for taking action locally.

Here’s a link to the authors’ Costs-of-Care website, where you will find information on ordering the book.

The PARADIGM-HF trial of LCZ696 — a novel compound that both blocks the renin-angiotensin system with an ARB component and blocks neprilysin’s degradation of natriuretic peptides — increased survival in heart failure by some 20% relative to enalapril. It seems to be a big deal, and the trial’s two principal authors have agreed to talk about their work and its larger meaning.

Running time: 15 minutes

Other links:

The study in the New England Journal of Medicine (free)

NEJM Journal Watch coverage of the study (free)

Running time: 9 minutes

In the light of the New England Journal of Medicine‘s recent publication three papers on sodium intake and its implications for cardiovascular disease, blood pressure, and excess mortality, we thought we’d speak again with Dr. Jan Staessen, who surprised a lot of people 3 years ago with a paper in JAMA warning against population-wide sodium reductions. His research showed that cutting sodium intakes to levels recommended by the U.S. Dept. of Agriculture was associated in his cohort with an increase in cardiovascular risk.

Dr. Staessen kindly agreed to serve as our guide through the new NEJM research.

LINKS:

The 2011 Staessen interview

Physician’s First Watch coverage of the new NEJM studies

Running time: 15 minutes

Dr. Danielle Ofri, author and internist (as well as an aspiring cellist), is writing a book about how patients and clinicians hear each other. Our discussion centers on that, and on her request that you contact her if you can put her in touch with great diagnosticians (and maybe even their patients).

If you have any suggestions about this or other matters, please contact me here: jelia@nejm.org.

Dr. Ofri may be contacted at her website: http://danielleofri.com

 Here’s a link to our 2009 interview with Ofri.

Spend 15 minutes with Dr. Natalia Shevchuk, whom we interviewed by candlelight last month. She is sheltering in the Odessa region now, having left the Donetsk area.

This time, she relates how she lost a colleague in Russia’s attack on the Kramatorsk railway station and found another she’d feared lost in Mariupol. She told us that she’s impressed by her patients’ willingness to fight, despite their opioid dependence.

The narrative can be confusing at times, and following closely will require having a map of Ukraine handy. A technical glitch or two complicated things, but you’ll get the main idea: Ukraine needs help.

[Running time: 15 minutes]

Running time: 10 minutes

The Institute of Medicine’s report on treatment for post-traumatic stress disorder finds that active military and veterans with PTSD aren’t always getting evidence-based treatments. And when those treatments are used, they’re too often not used according to protocols and the results aren’t measured. The upshot? The agencies with responsibility for treating PTSD don’t know whether they’re doing their patients any good.

Institute of Medicine report on PTSD (free)

Dr. Charlotte Yeh was crossing the street in Washington, D.C., on her way to dinner when a car hit her.

She ended up in a Level I trauma center, and the experience was sobering for its reminder that in our drive to measure quality indicators, the patient may end up ignored or forgotten.

Running Time: 10 minutes

A link to her essay in Health Affairs

 Running time: 11 minutes

The American Heart Association/American College of Cardiology have released four sets of guidelines — all aimed at the lowering of risk for atherosclerotic cardiovascular disease. For perspective, we’ve asked Harlan Krumholz, editor-in-chief of NEJM Journal Watch Cardiology and CardioExchange to chat.

Links:

Risk calculator (free)

CardioExchange (free)

Circulation homepage

New York Times piece by Krumholz on the guidelines (free)

Running time: 10 minutes

The Camden Coalition of Healthcare Providers formed about 10 years ago as a quarterly breakfast club of primary-care providers who were frustrated in their attempts to bring care to comprehensive care to their patients in Camden, N.J.

The Coalition’s found and executive director, Dr. Jeffrey Brenner (himself a family physician) has just been awarded a MacArthur Foundation fellowship, and so we caught up with him for a quick chat.

Link:

The coalition’s website

Running time: 7 min

The recent JAMA article examining the effects of the “polypill” on adherence and clinical benefits in patients with (or at high risk for) cardiovascular disease, is our topic. The polypill in this trial contained fixed doses of four separate drugs: aspirin, a statin, lisinopril and one other blood-pressure-lowering drug — either atenolol or hydrochlorothiazide.

Adherence among patients on the polypill was 20 percentage points higher than among those following regular multi-pill regimens. It was even higher — by some 40 percentage points — among those least adherent to their regimens at the start of the 15-month trial.

Dr. Anthony Rodgers of the University of Sydney — the paper’s senior author — talks with us about the trial.

Links:

Physician’s First Watch coverage of the trial (free)

JAMA article (free)

Running time: 19:45

This week’s guest is Yoanna Skrobik, a Montreal intensivist and author of an intriguing commentary on a Lancet Respiratory Medicine paper on the (non)effect of haloperidol in influencing the incidence or length of delirium/coma in critically ill patients.

Physician’s First Watch coverage of the Lancet articles

Nurse-facilitated family participation

Early physical/occupational therapy in mechanically ventilated patients

Running time: 14 minutes.

A study in Diabetes Care shows that people at higher genetic risk for diabetes and cardiovascular complications had a relatively lower stroke risk when they adhered to a Mediterranean diet. Dr. Jose Ordovas, the study’s senior author, is our guest for this discussion about the interaction between genes and diet — and its implications even for those without risky genetics.

Diabetes Care abstract (free)

Physician’s First Watch summary (free)

Running time: 11 minutes

Last month John You and his colleagues published a guide to discussing advance care planning with patients at high risk of dying in the Canadian Medical Association Journal.

It’s full of practical advice, and I thought it would be interesting to get a sense of You’s approach to this difficult issue that all clinicians confront sooner or later.

Links:

Physician’s First Watch coverage of the CMAJ paper.

Link to the prognosis estimators.

Dr. Brien Barnewolt of Tufts Medical Center shares his thoughts on the aftermath of the April 15 bombings at the Boston Marathon. Simple things matter in these circumstances, like wearing your ID badge.

Length: 9 minutes

Andrew Ulrich, executive vice chair of Boston Medical Center’s emergency department and an associate professor of emergency medicine at Boston University School of Medicine talks about the day and its lessons. He was just starting his shift when victims began arriving.

We’ll continue our explorations of the bombings, trying at least to salvage some lessons. If you have suggestions for the series — or thoughts on Clinical Conversations — please share them via the “add a comment” link below.

Joe Elia

Last week’s conversation with Alasdair Conn

During the American Academy of Neurology’s 2022 meeting in Seattle, Dr. Richard Lipton of Albert Einstein College of Medicine took questions from Dr. Teshamae Monteith (U. Miami) and Joe Elia.

Lipton’s group sought to characterize the impact of patients’ monthly headache days on their quality of life, especially the role of depression, allodynia, and anxiety. (Read the conference’s abstract here.)

[Listening time: 14 minutes]

Please leave a comment below to suggest how we can improve these interviews.

Alasdair Conn, chief of emergency services at Massachusetts General Hospital and an associate professor of surgery at Harvard Medical School continues our series on the aftermath of the Boston Marathon bombings.

Thank you for listening. Do let us know what you think.

Joe Elia

Links:

Dr. Conn’s essay in the Annals of Internal Medicine

Last week’s conversation with Dr. Ron Walls

Thank you for your questions about the status of Clinical Conversations. We’re edging our way back toward a normal schedule with this, the first of a planned multipart series on the lessons learned in the aftermath of the Boston Marathon bombings.

Ron M. Walls, professor and chair of the department of emergency medicine at Brigham and Women’s Hospital and Harvard Medical School is the guest. Listen in and please let us know what you think.

Joe Elia

Link:

The JAMA “Viewpoint” piece written with Michael Zinner.

Running time: 20 min.

In some diseases there are two diagnoses to make: the clinical diagnosis and the diagnosis of what the patient’s treatment preference is. The first is hard enough to make, and the widening choice of treatment choices complicates the second.

Welcome to the task of “preference diagnosis,” which can lead to disappointment and worse if missed in diseases like breast or prostate cancer.

We talk this week with the authors of an essay on the topic in BMJ. They offer some advice and some resources you’ll find useful.

Links:

• First Watch coverage (free)
• “Option grid” from Cardiff University (free)
• BMJ essay (free)