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Author Interviews, C. difficile, Hospital Acquired, JAMA / 05.05.2015

Dale N. Gerding, MD Research Physician, Edward Hines, Jr., VA Hospital Professor, Department of Medicine of Loyola University Chicago Stritch School of MedicineMedicalResearch.com Interview with: Dale N. Gerding, MD Research Physician, Edward Hines, Jr., VA Hospital Professor, Department of Medicine of Loyola University Chicago Stritch School of Medicine Medical Research: What is the background for this study? What are the main findings? Dr. Gerding: Naturally occurring strains of C. difficile lack the genes for production of the toxins that cause C. difficile infection (CDI) and are known as non-toxigenic C. difficile (NTCD). These strains when ingested by patients whose normal microbiota is disrupted by antibiotic treatment will harmlessly colonize the colon and remain in the gut for weeks to months. Specific strains of NTCD found in patients were shown to colonize the gut and prevent C. difficile infection when challenged with toxigenic C. difficile strains in animal models. One such NTCD strain, NTCD-M3, was shown to be safe and well tolerated in human volunteer trials and was used in the present study to determine if it would prevent recurrence of C. difficile infection in patients who had just completed treatment with vancomycin or metronidazole of either their first CDI episode or first recurrence of C. difficile infection. 168 patients were randomized to receive by mouth in a liquid form, either 10,000 spores/day of NTCD-M3 for 7 days, 10 million spores/day for 7 days, 10 million spores/day for 14 days, or an identical placebo for 14 days.  Primary outcome was safety, and secondary outcomes were the percent who colonized the gut with NTCD-M3 in the time period from end of treatment to week 6, and the rate of recurrent CDI in the patients at week 6. The results showed that NTCD-M3 was safe and well tolerated, and colonized the gut of 69% of patients who received it. The C. difficile infection recurrence rate was 30% in the placebo patients and 11% in patients who received any of the NTCD-M3 doses (P<.006). The best dose tested was 10 million spores/day for 7 days which resulted in a recurrence rate of only 5% (p<.01 vs placebo). Colonization of the gut was not permanent, but lasted a maximum of 22 weeks. The summary conclusion is that NTCD-M3 is safe, colonized the gut, and when it colonized the gut, reduced recurrence of C. difficile infection to 2% (p<.001 vs patients who were not colonized). (more…)
Author Interviews, Brain Injury, JAMA, Pediatrics / 04.05.2015

Thomas P. Dompier, PhD, ATC President and Injury Epidemiologist Datalys Center for Sports Injury Research and Prevention, Inc Indianapolis, IN 46202 Adjunct Faculty Appointments Ohio University Rocky Mountain University of Health Professions University of South CarolinaMedicalResearch.com Interview with: Thomas P. Dompier, PhD, ATC President and Injury Epidemiologist Datalys Center for Sports Injury Research and Prevention, Inc Indianapolis, IN 46202 Adjunct Faculty Appointments Ohio University Rocky Mountain University of Health Professions University of South Carolina Medical Research: What is the background for this study? D: Dompler: Per the Institute of Medicine’s recent recommendations to better describe the incidence of concussion in sport across the entire spectrum of youth sports (5-23 years), this study is the first to provide an apples-to-apples comparison using epidemiologic data provided by healthcare providers (athletic trainers) who attended all practices and games and used the same methodology to report concussions and student-athlete exposure information. Medical Research: What are the main findings? D: Dompler: a.  The main findings are that the risk (how many players out of 100 can expect to suffer at least one concussion during the season) is lowest in the youth, and increases with age. b. Game concussion rates (how many players out of 1000 exposed during a practice or game, includes multiple concussions to the same player) are highest in college but practice concussion rates are lowest in college during practice.  This suggests more can be done during high school and youth practices to reduce concussion frequency (e.g. limiting how much time can be devoted to full contact, reducing player-to-player contact by teaching proper tackling without using full contact drills such as the Oklahoma drill and others). c. While the rate is higher, there is still a substantial number of concussions that occur during practice (because there are more practices), therefore sports medicine staff should be available at both if possible (this is difficult at the youth level because of cost, however). (more…)
Author Interviews, Blood Pressure - Hypertension, JAMA, Salt-Sodium / 29.04.2015

Lynn L. Moore, DSc, MPH Department of Medicine Boston University School of Medicine Boston, Massachusetts MedicalResearch.com Interview with: Lynn L. Moore, DSc, MPH Department of Medicine Boston University School of Medicine Boston, Massachusetts Medical Research: What is the background for this study? Dr. Moore: The USDA’s current Dietary Guidelines for sodium intake have become increasingly controversial. Current recommendations include restricting sodium intake after the age of 2 years to no more than 2300 mg per day. For African-American adults and children, intakes should be restricted to no more than 1500 mg per day. Actual intake levels are much higher, with most Americans consuming about 3500 mg per day. Our goal was to estimate the effects of dietary sodium and potassium intakes on the change in blood pressure throughout adolescence. We used data from the National Growth and Health Study, a prospective study of more than 2000 girls who were 9-10 years of age at the time of enrollment. Lifestyle factors were assessed repeatedly throughout the study, and blood pressure was measured annually. Dietary sodium and potassium were assessed using multiple sets of three-day diet records. We used longitudinal modeling to estimate the effects of dietary sodium and potassium on blood pressure change over 10 years. Medical Research: What are the main findings? Dr. Moore: In this study, there was no evidence for a beneficial effect of reduced sodium intake on blood pressure change during adolescence. By 19-20 years of age, girls who consumed more than 4000 mg of sodium per day had systolic and diastolic blood pressure levels that were similar to those seen among girls with lower levels of sodium intake. Specifically, there was no beneficial effect on blood pressure associated with sodium intakes of less than 2500 mg per day. These results were similar for blacks and whites. In contrast, the repeated measures analyses showed that girls who consumed more than 2400 mg of potassium per day had lower blood pressures throughout adolescence compared with girls consuming less than 1800 mg per day of potassium. (more…)
Alzheimer's - Dementia, Author Interviews, Diabetes, JAMA / 28.04.2015

MedicalResearch.com Interview with: Dimitry S. Davydow, MD, MPH Associate Professor Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine Seattle, WA 98195 Dr, Davydow wishes to acknowledge Dr. Wayne Katon, the lead investigator of the study, who passed away on March 1, 2015. Medical Research: What is the background for this study? Dr. Davydow: The medical and public health communities have known for quite a while that diabetes and depression are both potential risk factors for developing dementia later in life. Dr. Wayne Katon previously published two articles detailing the results of two studies of relatively large groups of patients (one with nearly 4,000 patients and the other with 29,000 patients) with diabetes showing that those with diabetes and co-existing depression had a greater risk of developing dementia later in life than those patients with just diabetes. These initial studies were important since patients with diabetes are 3 to 4-times more likely to suffer from depression compared to the general population. However, it remained unclear when comparing to a population without either diabetes or depression, to what extent each independently raised the risk of developing dementia, and then to what extent having both conditions increased an individual’s subsequent risk of dementia. We sought to answer these questions with this study. In addition, with the growing obesity epidemic, which carries with it higher burdens of both diabetes and depression, there is reason to be concerned that the risk of dementia could be higher at even younger ages. To address this issue, we also wanted to see if there was a differential impact of the combination of diabetes and co-existing depression on dementia risk among those younger than 65 compared to individuals 65 or older. We were fortunate to be able to examine health data from all Danish citizens 50 or older over a 6 year period, a population numbering nearly 2.5 million people to be able to answer these questions. Medical Research: What are the main findings? Dr. Davydow: We found that compared to individuals without diabetes or depression, those with diabetes alone had about a 15% greater risk of developing dementia, those with depression alone had about an 83% greater risk of developing dementia, and those with both diabetes and co-existing depression had a 107% greater risk of developing dementia compared to those without either condition. We also found that of all of the cases of dementia diagnosed in Denmark among individuals 50 or older between 2007 through 2013, 6% were potentially due to combination of having both diabetes and depression. This was also true for those 65 or older, where 6% of all diagnosed dementia was potentially attributable to the combination of both diabetes and depression. However, among individuals under age 65, we found that 25% of all cases of dementia may have been directly attributable to the combination of diabetes and co-existing depression. (more…)
Author Interviews, End of Life Care, Heart Disease, JAMA, Kidney Disease / 27.04.2015

MedicalResearch.com Interview with: Susan P. Y. Wong, M.D. Acting Instructor & Senior Research Fellow Division of Nephrology University of Washington Medical Research: What is the background for this study? What are the main findings? Dr. Wong: There is a paucity of information on the use of cardiopulmonary resuscitation (CPR) and its outcomes among patients receiving maintenance dialysis. To address this knowledge gap, we performed a retrospective study to define contemporary trends in in-hospital CPR use and its outcomes among a nationally representative sample of 663,734 patients receiving maintenance dialysis between 2000 and 2011. We found that in-hospital CPR use among this cohort of patients was very high—nearly 20 times more common than that found in the general population. The rate of in-hospital CPR use has also been increasing among patients receiving maintenance dialysis despite evidence of poor long-term survival among these patients. Median survival after hospital discharge for members of this cohort was only 5 months, and this has not change substantially in the recent decade. We also found that a large proportion  of dialysis patients who died in hospital settings had received CPR during their terminal hospitalization. This proportion has also been steadily increasing over time, and in 2011, 1 in 5 dialysis patients who died in hospital had received CPR during their terminal hospitalization. (more…)
Author Interviews, Autism, Education, Emory, JAMA, Pediatrics / 22.04.2015

MedicalResearch.com Interview with: Lawrence Scahill, MSN, PhD and Karen Bearss, PhD Department of Pediatrics, Marcus Autism Center Children’s Healthcare of Atlanta and Emory University Atlanta, Georgia Medical Research: What is the background for this study? What are the main findings? Response: Autism spectrum disorder (ASD) affects an estimated 0.6 to 1% of children worldwide. In young children with ASD (e.g. 3 to 7 years of age) up to 50% also have disruptive behaviors such as tantrums, aggression, self-injury and noncompliance. When present, these disruptive behaviors interfere with the child’s readiness to make use of educational and other supportive services. The presence of disruptive behaviors also hinders the acquisition of routine daily living skills. Parent Training has been shown to be effective for young children with disruptive behaviors who do not have Autism spectrum disorder – but it has not be well-studied in children with ASD. The current multisite study shows that parent training is effective in reducing serious behavioral problems in young children with ASD. This is the largest randomized trial of a behavioral intervention in children with ASD.  180 children were randomly assigned to parent training or parent education. Both treatments were delivered individually to parents over 24 weeks. Serious behavioral problems were reduced by almost 50% in the parent-training group compared to about 30% for parent education. A clinician who was blind to treatment assignment rated positive response in 69% of children in the parent training group compared to 40% for parent education. In addition, 79% of children who showed a positive response to parent training at the end of the 24-week trial maintained benefit at 6 months post treatment. Parent training provided parents with specific strategies on how to manage tantrums, aggression, self-injury and noncompliance in children with autism spectrum disorder. Parent education provided up-to-date and useful information about ASD, but no instruction on how to address behavioral problems. Parents were engaged in the study treatments as evidenced by the low drop-out rate of 10% . (more…)
Author Interviews, End of Life Care, JAMA, Outcomes & Safety / 15.04.2015

Mihaela S Stefan, MD FACP Research Scientist, Center for Quality of Care Research Director of Outpatient Perioperative Clinic and Medical Consultation Program Academic Hospitalist Baystate Medical Center Assistant Professor of Medicine, Tufts University School of Medicine Springfield MA 01199MedicalResearch.com Interview with: Mihaela S Stefan, MD FACP Research Scientist, Center for Quality of Care Research Director of Outpatient Perioperative Clinic and Medical Consultation Program Academic Hospitalist Baystate Medical Center Assistant Professor of Medicine, Tufts University School of Medicine Springfield MA 01199 MedicalResearch: What is the background for this study? Dr. Stefan : Mortality rates for patients with pneumonia are publicly reported and are used to evaluate hospital performance. The rates are calculated using Medicare administrative claims data which provide limited insight into severity of illness and comorbidities that may be associated with death. The mortality measure does not take into consideration advance directives or changes in goals of care preferences during hospitalization. MedicalResearch: What are the main findings? Dr. Stefan : In this retrospective chart review of 202 adults who died with a principal diagnosis of pneumonia between January 2008 and December 2012 in 3 hospitals in MA, we assessed the proportion of patients for whom pneumonia was determined to play a major or a minor role in the patient death. Pneumonia was considered a minor cause if the patient had advanced life threatening illnesses and this was found in 82% of the deaths. More than half of the patients were DNR at admission to the hospital. The majority of patients who died were frail elderly with life-threatening conditions who decided to forgo aggressive care at some point during their admission. Only a small fraction of deaths in the pneumonia mortality measure were the direct result of pneumonia. (more…)
Author Interviews, Depression, JAMA, Race/Ethnic Diversity, University of Michigan / 11.04.2015

Addie Weaver PhD Research Investigator and LEO Adjunct Lecturer School of Social Work University of MichiganMedicalResearch.com Interview with: Addie Weaver PhD Research Investigator and LEO Adjunct Lecturer School of Social Work University of Michigan Medical Research: What is the background for this study? What are the main findings? Dr. Weaver: The mental health of both African Americans and rural Americans has been understudied. Though depression is one of the most common, debilitating mental illnesses among women, very little is known about depression among African American women living in rural areas of the United States. In fact, much of what we know about rural women's depression in general is based on research conducted with community samples, as limited epidemiolgical research includes large enough samples of both African American respondents and rural respondents to assess potentially important subgroup differences by urbanicity (e.g., urban, suburban, rural) and race. Our study used the National Survey of American Life, the first and only nationally representative survey of African Americans, to examine the interaction of urbanicity and race/ethnicity on Major Depressive Disorder and mood disorder prevalence among African American and non-Hispanic white women residing in the South. We found that rural residence has a differential effect on depression and mood disorder for African American women and non-Hispanic white women. Overall, African American women living in rural areas experienced significantly lower odds of meeting criteria for lifetime and 12-month Major Depressive Disorder and lifetime and 12-month mood disorder than urban African American women. Conversely, non-Hispanic white women residing in rural areas had significantly higher odds of meeting criteria for lifetime and 12-month Major Depressive and lifetime and 12-month mood disorder when compared to rural African American women, and had significantly higher prevalence rates of 12-month Major Depressive Disorder and 12-month mood disorder than urban non-Hispanic white women. All analyses controlled for age, education level, household income, and marital status, suggesting that the urbanicity differences were not due to resource disparities often experienced by individuals residing in rural communities. (more…)
Author Interviews, Cancer Research, Cost of Health Care, JAMA / 10.04.2015

Gabriel Brooks, MD Gastrointestinal Cancer Center Dana-Farber Cancer Institute MedicalResearch.com Interview with: Gabriel Brooks, MD Gastrointestinal Cancer Center Dana-Farber Cancer Institute Medical Research: What is the background for this study? What are the main findings? Dr. Brooks: The background for our study is that hospitalizations in patients with cancer are common, costly, and distressing to patients.  Acute hospital care is the single largest expenditure category in cancer care, accounting for substantially greater costs than even chemotherapy. However, patients generally wish to avoid hospitalization, and they certainly want to avoid complications of treatment that can lead to hospitalization. For these reasons, we sought to identify the extent to which hospitalizations are perceived as potentially avoidable by clinicians who are directly involved in patient care. We interviewed three physicians for each of 103 patients with cancer who experienced a hospitalization. For 24 patients (23%) two or more of the three physicians agreed that hospitalization had been potentially avoidable. (more…)
Author Interviews, Genetic Research, JAMA, Melanoma / 10.04.2015

Nancy E. Thomas, MD, PhD Department of Dermatology University of North CarolinaMedicalResearch.com Interview with: Nancy E. Thomas, MD, PhD Department of Dermatology University of North Carolina MedicalResearch: What is the background for this study? Dr. Thomas: BRAF and NRAS mutations found in melanomas are important for tumor initiation and maintenance. There are drugs that target BRAF mutations or the pathway that are approved for BRAF-mutant metastatic melanoma and help improve survival. However, it remains unknown whether these mutations in primary melanoma are markers for melanomas with a worse prognosis. MedicalResearch: What are the main findings? Dr. Thomas:
  • In a large international population-based study, we found that of primary melanomas, 30% harbor BRAF mutations, 13% have NRAS mutations and the other 57% do not have these mutations (wildtype).
  • In higher primary tumor stage melanomas, BRAF or NRAS mutations were associated with an approximately 3-fold increased rate of death from melanoma compared to wildtype melanoma adjusted for other prognostic factors.
  • Primary melanomas with NRAS mutations were less likely to have tumor infiltrating lymphocytes (TILs) in the tumor microenvironment. (more…)
Author Interviews, JAMA, Surgical Research, UCSF / 07.04.2015

Emily Finlayson, MD, MS Department of Surgery, Division of General Surgery Department of Medicine, Division of Geriatrics Philip R Lee Institute for Health Policy University of California, San Francisco Director, UCSF Center for Surgery in Older AdultsMedicalResearch.com Interview with: Emily Finlayson, MD, MS Department of Surgery, Division of General Surgery Department of Medicine, Division of Geriatrics Philip R Lee Institute for Health Policy University of California, San Francisco Director, UCSF Center for Surgery in Older Adults Medical Research: What is the background for this study? What are the main findings? Dr. Finlayson: In general, the goal of lower extremity revascularization is to preserve the leg so that patients can maintain the ability to ambulate and maintain functional independence.  We evaluated the results of this operation in older nursing home residents in the United States.  We found that over the 3 year study period, over 10,000 nursing home residents underwent this procedure.  Most of them were functionally dependent before surgery, 3/4 were unable to walk, and over half had dementia. After 1 year, half of the residents had died.  Among residents who could not walk before surgery, 89% were dead or non ambulatory 1 year after surgery. (more…)
Author Interviews, Brigham & Women's - Harvard, Cannabis, JAMA, Lipids, Pediatrics / 06.04.2015

Holly Gooding, MD, MS Harvard T.H. Chan School of Public Health Instructor in Pediatrics at Harvard Medical School Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital Division of General Internal Medicine, Brigham and Women’s Hospital Boston, MAMedicalResearch.com Interview with: Holly Gooding, MD, MS Harvard T.H. Chan School of Public Health Instructor in Pediatrics at Harvard Medical School Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital Division of General Internal Medicine Brigham and Women’s Hospital Boston, MA Medical Research: What is the background for this study? What are the main findings? Dr. Gooding: As an adolescent medicine physician, I primarily care for patients between the ages of 12 and 30, although I first trained in internal medicine.  One of the things I noticed when I started working with this age group is that pediatric and adult guidelines differ for many conditions.  Cholesterol treatment is one condition that comes up frequently, because the NHLBI and the AAP recommend screening youth ages 17 to 21 for cholesterol problems. The study team and I set out to discover the proportion of American youth ages 17 to 21 who would meet criteria for pharmacologic treatment of abnormal cholesterol levels if clinicians applied the pediatric versus the adult guidelines.  We found that 2.6% of young people ages 17 to 21 would qualify for pharmacologic treatment of abnormal LDL cholesterol levels under the pediatric guidelines, but less than 1% would qualify under the adult guidelines.  This translates to almost 500,000 youth qualifying for treatment under the pediatric guidelines, but only about 78,000 under the adult guidelines.  Those who met pediatric criteria had lower LDL levels but higher proportions of high blood pressure, smoking, and obesity. (more…)
Author Interviews, Exercise - Fitness, JAMA, NIH / 06.04.2015

MedicalResearch.com Interview with: Hannah Arem, MHS, PhD Division of Cancer Epidemiology and Genetics National Cancer Institute, Bethesda, MarylandMedicalResearch.com Interview with: Hannah Arem, MHS, PhD Division of Cancer Epidemiology and Genetics National Cancer Institute, Bethesda, Maryland Medical Research: What is the background for this study? Dr. Arem: The 2008 Physical Activity Guidelines for Americans recommend a minimum of 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity activity per week for “substantial” health benefit, and suggest “additional” benefit with more than double the exercise minimum. However, the guidelines note that there is a lack of evidence for an upper limit of health benefit. We set out to define the dose-response relationship between leisure-time physical activity and mortality and to determine the upper limit of benefit associated with higher levels of aerobic exercise. Medical Research: What are the main findings? Dr. Arem: We found that study participants who met the recommended minimum level of leisure-time physical activity derived most of the mortality benefit, with a 31% lower risk of death compared to inactive individuals. Study participants who engaged in three to five times the recommended minimum level of leisure-time physical activity had a marginally increased mortality benefit, with a 39% lower risk of death compared to inactive individuals. Three to five times the recommended minimum is equivalent to a weekly minimum of walking 7 hours or running 2 hours 15 minutes. (more…)
Author Interviews, Exercise - Fitness, JAMA / 06.04.2015

Klaus Gebel GradDipExRehab, MExSc, MAppSc, PhD Senior Research Fellow Centre for Chronic Disease Prevention College of Public Health, Medical & Veterinary Sciences James Cook University Cairns AUSTRALIAMedicalResearch.com Interview with: Klaus Gebel GradDipExRehab, MExSc, MAppSc, PhD Senior Research Fellow Centre for Chronic Disease Prevention College of Public Health, Medical & Veterinary Sciences James Cook University Cairns Australia Medical Research: What is the background for this study? Response: The physical activity guidelines in most countries recommend for adults to accumulate at least 150 minutes of moderate physical activity (e.g. brisk walking) or 75 minutes of vigorous activity (e.g. jogging or cycling) or an equivalent combination of moderate and vigorous activities where 2 minutes of moderate-intensity activity counts the same as 1 minute of vigorous-intensity activity. However, there have only been a few studies that examined the health benefits of different proportions of moderate and vigorous activity in the composition of total activity. The objective of this study was to examine whether the proportion of total moderate-to-vigorous activity that is achieved through vigorous activity is associated with all-cause mortality, independently of the total amount of moderate-to-vigorous activity. Data were used from the 45 and Up study from the state of New South Wales in Australia, the largest cohort study ever conducted in the Southern hemisphere. Medical Research: What are the main findings? Response: During 1,444,927 person-years of follow-up, 7,435 deaths were registered. Compared with those who reported no moderate-to-vigorous activity (crude death rate=8.34%), the adjusted hazard ratios for all-cause mortality were 0.66 (95% CI 0.61-0.71; crude death rate=4.81%), 0.53 (0.48-0.57; 3.17%), and 0.46 (0.43-0.49; 2.64%) for reporting 10-149, 150-299, and for ≥300 minutes of activity per week respectively. Among those participants who reported any moderate-to-vigorous physical activity, the proportion of vigorous activity showed a dose-response relationship with all-cause mortality: compared with those reporting no vigorous activity (crude death rate=3.84%) the fully-adjusted hazard ratio was 0.91 (95% CI=0.84-0.98; crude death rate=2.35%) in those who reported some vigorous activity (but <30% of total activity); and 0.87 (0.81-0.93; 2.08%) among those who reported ≥30% of activity as vigorous. These associations were consistent in men and women, across categories of body mass index and volume of moderate-to-vigorous physical activity, and in those with and without existing cardiovascular disease or diabetes mellitus. (more…)
Author Interviews, HIV, JAMA, Pediatrics, University of Pennsylvania / 02.04.2015

Elizabeth Lowenthal, MD MSCE Assistant Professor of Pediatrics Children's Hospital of PhiladelphiaMedicalResearch.com Interview with: Elizabeth Lowenthal, MD MSCE Assistant Professor of Pediatrics Children's Hospital of Philadelphia Medical Research: What is the background for this study? What are the main findings? Dr. Lowenthal: Between 2005 and 2012, HIV related deaths declined by 30% worldwide. However, during the same time period, HIV related deaths increased 50% among adolescents. Over 90% of HIV-infected children and adolescents live in sub-Saharan Africa and HIV is the leading cause of death among adolescents in Africa. Treatment is available that can allow babies born with HIV to live to be healthy adults. However, strict adherence to these medicines is necessary and often becomes a great challenge during adolescence. In our study of 300 adolescents (ages 10-19) in Botswana, my team found that adolescents who come to clinic without a parent or guardian have a 4.5X greater odds of failing their HIV treatment. (more…)
Author Interviews, JAMA, Mental Health Research, Pediatrics / 01.04.2015

Dr. Julie Magno Zito, PhD University of Maryland, Baltimore, MD 21201MedicalResearch.com Interview with: Dr. Julie Magno Zito, PhD University of Maryland, Baltimore, MD 21201 MedicalResearch: What is the background for this study? Dr. Zito: Atypical antipsychotic (AAP) use in children and adolescents has grown substantially in the past decade, largely for behavioral (non-psychotic) conditions. Poor and foster care children with Medicaid-insurance are particularly affected. This ‘off-label’ usage has insufficient evidence of benefits regarding improved functioning (i.e. appropriate behavior and performance, socially and academically) while the little evidence that accrues tends to emphasize ‘symptoms’, i.e. less acting out. Recent evidence shows that youth treated with atypical antipsychotics are at risk of serious cardiometabolic adverse events including diabetes emerging after atypical antipsychotics are ‘on board’. (more…)
Author Interviews, JAMA, Melanoma, Technology, UCSF / 01.04.2015

Maria L. Wei, M.D., Ph.D. Associate Professor of Dermatology Director, Melanoma Surveillance Clinic Multidisciplinary Melanoma Program University of California, San Francisco Staff Physician Veterans Affairs Medical Center, San FranciscoMedicalResearch.com Interview with: Maria L. Wei, M.D., Ph.D. Associate Professor of Dermatology Director, Melanoma Surveillance Clinic Multidisciplinary Melanoma Program University of California, San Francisco Staff Physician Veterans Affairs Medical Center, San Francisco Medical Research: What is the background for this study? Dr. Wei: Effective physician-patient communication is essential for optimal medical care. There are now many methods available to notify patients of their biopsy results: a clinic visit (the method traditionally preferred by patients), a telephone call, secure online patient portals to access medical charts, email and texts. In addition, there is variability from state to state in the guidelines regulating the release of biopsy results online. Until recently, some states did not allow the on-line release of biopsy results. There have been few systematic studies on patient preferences for communication of biopsy results. (more…)
Author Interviews, Diabetes, JAMA, Pediatrics / 01.04.2015

MedicalResearch.com Interview with: Dr. Michele Jonsson Funk, PhD Research Associate Professor, Dept of Epidemiology Director, Methods Core, Center for Women’s Health Research University of North Carolina at Chapel Hill and Dr. Wendy Camelo Castillo, MD, PhD Post-doctoral fellow at the University of Maryland Medical Research: What is the background for this study? Response: Gestational diabetes is a condition that affects between 8-11% of pregnant women worldwide. In the United States, the prevalence of gestational diabetes has more than doubled since the 1990’s. Most women can control their blood glucose levels with changes in diet and exercise, but approximately 10% need to take medication during pregnancy. Over the last decade, the use of glyburide (a pill) to manage gestational diabetes has increased and it is now used more often than insulin (an injectable). Medical Research: What are the main findings? Response: Treatment with glyburide (compared with insulin) was associated with higher risks of admission to the neonatal intensive care unit (NICU) (by 41%), respiratory distress (by 63%), hypoglycemia in the newborn (40% ), birth injury (35% ) and being large for gestational age (43% ).  The risk of NICU admission, large for gestational age and respiratory distress between glyburide and insulin treated women was increased by 3.0%, 1.4% and 1.1% respectively. (more…)
Author Interviews, Heart Disease, Imperial College, JAMA, Outcomes & Safety / 01.04.2015

intra-aortic balloon pump, WikipediaMedicalResearch.com Interview with: Sayan Sen, PhD International Centre for Circulatory Health, National Heart and Lung Institute Imperial College London London, United Kingdom Medical Research: What is the background for this study? What are the main findings? Dr. Sayan Sen: Intra-aortic balloon pumps (IABP) are often used in Acute Myocardial Infarction, particularly in patients with cardiogenic shock. We analysed the available Randomized Controlled Trials (RCT) and observational studies, spanning 30 years, to establish the evidence for this use. There is no identifiable group of patients with Acute Myocardial Infarction that have been demonstrated to derive a mortality benefit from insertion of an IABP. The studies, including over 17000 patients, have studied mortality in patients receiving IABP in comparison to mortality of patients that received no IABP in the era of no reperfusion, fibrinolysis and primary percutaneous intervention.  This lack of mortality reduction with IABP in AMI is consistent in patients with and without cardiogenic shock across both RCTs and observational studies; questioning the continued use of this technology in Acute Myocardial Infarction. (more…)
Author Interviews, JAMA, OBGYNE, Toxin Research / 26.03.2015

Dr. Bradley S. Peterson, M.D Director of the Institute for the Developing Mind The Saban Research Institute of Children’s Hospital Los Angeles Children’s Hospital Los AngelesMedicalResearch.com Interview with: Dr. Bradley S. Peterson, M.D Director of the Institute for the Developing Mind The Saban Research Institute of Children’s Hospital Los Angeles Children’s Hospital Los Angeles Medical Research: What is the background for this study? Dr. Peterson: Neurotoxic PAH (polycyclic aromatic hydrocarbons) are ubiquitous in the environment, in the home and in the workplace. Emissions from motor vehicles, oil and coal burning for home heating or power generation, wildfires and agricultural burning, hazardous waste sites, tobacco smoke and charred foods are all sources of exposure. PAH readily crosses the placenta and affects an unborn child’s brain; earlier animal studies showed that prenatal exposure impaired the development of behavior, learning and memory. Our group previously reported that exposure to airborne PAH during gestation was associated with multiple neurodevelopmental disturbances, including development delay by age 3, reduced verbal IQ at age 5, and symptoms of anxiety and depression at age 7. Medical Research: What are the main findings? Dr. Peterson: Together with Virginia Rauh, ScD and Frederica Perera, DrPH, PhD of Columbia University’s Mailman School of Public Health, we conducted a brain imaging study to test the effects on brain structure of PAH exposure during the final trimester of pregnancy.  We used magnetic resonance imaging (MRI) to measure the brains of 40 children from a cohort of more than 600 mother-baby pairs from minority communities in New York City. These 40 children were carefully selected to have no other exposures that would affect brain development. Our findings showed that prenatal PAH exposure led to reductions in nearly the entire white matter surface of the brain’s left hemisphere – losses that were associated with slower processing of information during intelligence testing and more severe behavioral problems, including ADHD and aggression.  Postnatal PAH exposure – measured at age 5 – was found to contribute to additional disturbances in development of white matter in the dorsal prefrontal region of the brain, a portion of the brain that supports concentration, reasoning, judgment, and problem-solving ability. (more…)
Aging, Author Interviews, Exercise - Fitness, Frailty, JAMA, Vitamin D / 23.03.2015

MedicalResearch.com Interview with: Kirsti Uusi-Rasi, PhD, Adjunct Professor Senior Researcher UKK Institute for Health Promotion Research Tampere Finland Medical Research: What is the background for this study? What are the main findings? Dr. Kirsti Uusi-Rasi: Falls are the leading cause of unintentional injuries and fractures in older adults, head injuries and fractures being the most severe consequences. Therefore, falls prevention is important when trying to prevent injuries. There is strong high-quality evidence from previous studies that exercise that includes strength and balance training can reduce the risk of falling in older adults. However, there are also studies that have reported no benefit in reducing the actual incidence of falls. Effects of vitamin D have also been studied widely, and vitamin D is known to be vital for bone metabolism and health. However, results regarding effects on falls and fractures are inconsistent. Furthermore, persons with low vitamin D levels (serum 25OHD) have been associated with lower physical performance and greater decline in physical functioning, but clinical trials exploring the role of vitamin D in reducing falls and fractures and in improving physical functioning are inconclusive. Because there is hardly any evidence about exercise and vitamin D together, we investigated the separate and combined effects of multimodal exercise training and vitamin D supplementation in reducing falls and injurious falls among older women at risk for falling. We assigned 409 participants randomly to one of four groups with: 1)vitamin D 800 IU/day and exercise 2) placebo and exercise 3) vitamin D 800 IU/day without exercise 4) placebo without exercise. Exercise consisted of strength, balance, mobility and agility group training. At the end of two years, exercise seemed to be more effective in reducing injurious falls in this age group, with or without vitamin D. Exercise also improved physical functioning (strength, balance and mobility). In general, the training program was well tolerated with no severe adverse effects or injuries. Vitamin D helped maintain femoral neck BMD and increased trabecular bone density at the tibia. Our study also suggests that the current vitamin D recommendation (800 IU/d for older people) is adequate. (more…)
Author Interviews, Brigham & Women's - Harvard, Dermatology, JAMA / 22.03.2015

Dr. Arash Mostaghimi, MD, MPA Director of Dermatology Inpatient Service Brigham and Women’s Hospital Boston, MAMedicalResearch.com Interview with: Dr. Arash Mostaghimi, MD, MPA Director of Dermatology Inpatient Service Brigham and Women’s Hospital Boston, MA     Medical Research: What is the background for this study? What are the main findings? Dr. Mostaghimi: Spironolactone, a generic drug that’s been used in the clinic since 1959, is commonly prescribed for treating hormonal acne – acne that tends to affect the jaw line most commonly around the time of the month when a woman gets her period. The US Food and Drug Administration recommends frequent potassium monitoring in patients with heart failure who are taking spironolactone as a diuretic and antihypertensive treatment, but it’s been unclear if these guidelines should apply to healthy patients taking spironolactone for the treatment of acne, and, if so, how frequently such patients should have their potassium levels tested. My colleagues and I have found that for young, healthy women taking spironolactone to treat hormonal acne, potassium monitoring is an unnecessary health care expense. For the approximately 1,000 patients we studied, blood tests to monitor potassium levels did not change the course of treatment, but the tests cumulatively totaled up to $80,000. We suggest that routine potassium monitoring should no longer be recommended for this patient population in order to improve the patient care experience, decrease unnecessary office visits and reduce health care spending. (more…)
Author Interviews, Cognitive Issues, JAMA, University of Michigan / 18.03.2015

Donovan Maust, MD, MS Assistant Professor of Psychiatry University of Michigan Research Scientist, Center for Clinical Management Research VA Ann Arbor Healthcare SystemMedicalResearch.com Interview with: Donovan Maust, MD, MS Assistant Professor of Psychiatry University of Michigan Research Scientist, Center for Clinical Management Research VA Ann Arbor Healthcare System Medical Research: What is the background for this study? What are the main findings? Dr. Maust: From a recent government report, we known that about 1/3 of older adults with dementia in nursing homes and about 14% of those in the community have been prescribed an antipsychotic. While providers focus on what benefit the treatment they offer, it is important to also be aware of the potential harms, particularly when it is death. Prior estimates came from relatively short studies and showed a 1% increase. This paper finds that, over 180 days, the increased mortality comparing antipsychotic users to matched non-users is about 2 to 5 times higher. (more…)
Author Interviews, Brigham & Women's - Harvard, JAMA, Race/Ethnic Diversity, Surgical Research / 18.03.2015

Dr. Adil Haider, MD, MPH Kessler Director of the Center for Surgery and Public Health (CSPH) at Brigham and Women’s HospitalMedicalResearch.com Interview with: Dr. Adil Haider, MD, MPH Kessler Director of the Center for Surgery and Public Health (CSPH) at Brigham and Women’s Hospital Medical Research: What is the background for this study? Response: Disparities in the quality of care received by minority and low-income patients have been reported for years across multiple medical conditions, types of care, and institutions.  To determine whether clinicians’ unconscious race and/or social class biases correlated with a lower quality of care for minority patients and those of lower socioeconomic status, my colleagues and I conducted a web-based survey among 215 physicians at an academic, level one trauma center. Participants were asked to review eight clinical vignettes, and then respond to three questions about management of care after each. Following their response, a test known as an Implicit Association Test (IAT Test) was used to assess any unconscious preferences. Medical Research: What are the main findings? Response: We found that race and class biases, as measured by response time to a standardized Implicit Association Test, had no relationship to the way that patients were clinically treated. Whether the lack of association found between implicit bias and decision making in this study represents a true lack of association or the failure of clinical vignettes to capture the nuances of how implicit biases translate into management decisions remains unclear. Existing biases might influence the quality of care received by minority patients and those of lower socioeconomic status in real-life clinical encounters. (more…)
Author Interviews, Breast Cancer, JAMA / 18.03.2015

Joann G. Elmore M.D., M.P.H. Professor of Medicine, Adjunct Professor of Epidemiology, University of Washington School of Medicine Harborview Medical Center Seattle, WA 98104-2499MedicalResearch.com Interview with: Joann G. Elmore M.D., M.P.H. Professor of Medicine, Adjunct Professor of Epidemiology, University of Washington School of Medicine Harborview Medical Center Seattle, WA 98104-2499 MedicalResearch: What is the background for this study? What are the main findings? Dr. Elmore: It is estimated that 1.6 million women in the United States each year undergo a breast biopsy. By interpreting these biopsies under the microscope, pathologists provide diagnoses on a spectrum from benign, to atypia, to ductal carcinoma in situ (DCIS), to invasive cancer. Using these diagnostic classifications, clinical doctors work with their patients to decide if they are at increased risk of developing breast cancer in the future, which can lead to additional surveillance, or how to treat them when the diagnosis is invasive breast cancer. As misclassification of breast lesions by pathologists may contribute to overtreatment and undertreatment of breast disease, we decided to study the accuracy of breast pathology diagnoses in the U.S. In the Breast Pathology (B-Path) Study, we used a set of 240 breast biopsy cases to evaluate the interpretive accuracy of 115 U.S. pathologists who were actively interpreting breast biopsies in their clinical practices. Their diagnoses were compared with reference diagnoses established by a consensus panel of experienced breast pathologists. When the panel members each independently diagnosed the slides pre-consensus, they agreed unanimously on 75 percent of their diagnoses; ninety percent of the panel members’ initial independent diagnoses agreed with the final consensus-derived reference diagnoses. When comparing participating pathologists’ diagnoses to the reference diagnoses, we found overall agreement for 75 percent of interpretations. The concordance rate for invasive breast cancer was reassuringly high at 96 percent, and fairly high for benign findings without atypia at 87 percent. However, concordance was lower for atypia at 48 percent and for DCIS at 84 percent. This means that nearly one out of five pathologists disagreed on the diagnosis of DCIS. We found disagreement with the reference diagnosis to be statistically more frequent when pathologists had lower weekly case volumes or worked in smaller labs. Disagreement was also statistically significantly more likely when the patient had dense breast tissue on mammogram; however, the absolute difference was small. Our accuracy findings were not altered when we used different methods of defining the reference diagnosis. (more…)
Author Interviews, Infections, JAMA, University of Michigan / 17.03.2015

Lona Mody, MBBS, MSc Associate Division Chief, Clinical and Translational Research Associate Director, Clinical Programs, VA GRECC Associate Professor, Internal Medicine Research Associate Professor, Institute of Gerontology University of Michigan Geriatrics Ann Arbor, MIMedicalResearch.com Interview with: Lona Mody, MBBS, MSc Associate Division Chief, Clinical and Translational Research Associate Director, Clinical Programs, VA GRECC Associate Professor, Internal Medicine Research Associate Professor, Institute of Gerontology University of Michigan Geriatrics Ann Arbor, MI Medical Research: What is the background for this study? What are the main findings? Response: Over 1.5 million residents live in 15,600 Nursing Homes in the US. The acuity of illness in this population has increased substantially in the last decade, as has the risk of acquiring new infections. Multi-drug resistant organisms, also known as MDROs, are endemic in this setting with prevalence estimates upwards of 35% and surpassing those in the hospitals. Nursing homes historically have had few infection prevention resources, which contributes to these high rates. Patients with indwelling devices such as urinary catheters and feeding tubes present an attractive habitat for these ‘superbugs’ and thus carry the added burden of device-related infections. The authors examined the effect of a targeted infection program, or TIP, to reduce the prevalence of Multi-drug resistant organisms and new catheter or feeding tube infections among patients with indwelling devices. The TIP intervention was three-fold:
  1. Surveillance for infections and Multi-drug resistant organism colonization with regular feedback to facilities;
  2. Extensive and interactive staff education using adult learning theory about key infection prevention practices and hand hygiene; and
  3. Use of gowns and gown when providing assistance to patients for high-risk activities such as bathing and grooming.
Staff education emphasized precautionary measures against the spread of infection and included mock game shows, songs and dances. Hands were cultured for bacteria before and after hand washing. Outcomes were measured by results of the cultures taken for each patient and monitoring infection rates. A team of researchers from the University of Michigan and the Veterans Affairs Ann Arbor Health System has demonstrated that simple measures might be all it takes to push back at the spread of Multi-drug resistant organisms or ‘superbugs’ in nursing homes as well as reduce infections. In their study of patients with indwelling devices, MDROs were reduced by 23 percent among 418 residents in six southeast Michigan nursing homes who participated over the course of the three-year study. The numbers of catheter-associated urinary tract infections and MRSA acquisitions also decreased, 46 percent and 22 percent respectively. The trial examined the relationship between acquisition of antimicrobial resistance among nursing home and assisted living facility residents with the use of devices by adapting new methodological approaches and study designs to study infection prevention interventions including the use of cluster-randomized study design for infection prevention interventions, adopting adult learning practices to engage frontline healthcare personnel and using multi-anatomic site sampling to demonstrate effectiveness of the program. (more…)
AHRQ, Author Interviews, Cost of Health Care, JAMA, Medical Imaging, Pain Research / 17.03.2015

Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA 98104-2499MedicalResearch.com Interview with: Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA Medical Research: What is the background for this study? Dr. Jarvik:  When I arrived at the Univ of WA over 20 years ago, my mentor, Rick Deyo, had just finished leading a project that was responsible for developing one of the first set of guidelines for the diagnosis and treatment of acute low back pain. These guidelines, published in a booklet by AHRQ (then called AHCPR), recommended that patients with acute low back pain not undergo imaging for 4-6 weeks unless a red flag was present. One of the exceptions was that patients older than 50 could get imaged immediately, the rationale being that older adults had a higher prevalence of potentially serious conditions such as cancer, infections, etc, that would justify the early imaging. As a practicing neuroradiologist, it was clear that a potential problem with this strategy is that the prevalence of age-related changes, which may or may not be related to back pain, also increases with age. So earlier imaging of older adults would almost certainly reveal findings, and these could easily start a series of unfortunate events leading to potentially poor outcomes and more healthcare resource use. Thus this policy of early imaging of older adults didn’t entirely make sense. About 5 years ago, these guidelines hit home when I developed acute low back pain and since I was over 50 (barely) my doctor recommended that I get an imaging study. Being a knowledgeable patient and having a reasonable doctor, we mutually agreed not to get the study. I improved but that wasn’t the end of it. When we had the chance to apply for one of the CHOICE ARRA awards funded by AHRQ, we made answering this question of early imaging in older adults one of our primary goals. (more…)
Author Interviews, Dermatology, Infections, JAMA / 15.03.2015

MedicalResearch.com Interview with: Dr. Ana Ramírez-Boscá, MD Department of Dermatology and Clinical Research UnitDr. Ana Ramírez-Boscá, MD Department of Dermatology and Clinical Research Unit and Vicente Navarro-López, MD Clinical Research Unit and Infectious Diseases Unit Centro Dermatológico Estético, Alicante, SpainVicente Navarro-López, MD Clinical Research Unit and Infectious Diseases Unit Centro Dermatológico Estético, Alicante, Spain   MedicalResearch: What is the background for this study? What are the main findings? Response: Infections have been related with the pathogenesis of guttate psoriasis, however antibiotic treatment does not improve prognosis nor does it affect the evolution of the disease. The association between psoriasis and other infectious diseases has been reported as well, although in these cases there is scarce information on the causative microbial likely involved and the role of these bacteria in the pathogenesis of this skin disease. MedicalResearch: What are the main findings?  Response: Bacterial DNA may be detected in bloodstream of a significant proportion of patients with active plaque psoriasis. Increased levels of pro-inflammatory cytokines in patients with presence of bacterial DNA but not in patients without presence of bacterial genomic fragments suggest a role of bacterial DNA translocation in inducing an inflammatory response. (more…)