Podcasts about us preventive services task force

Evidence-based recommendations from groups like the US Preventive Services Task Force are only as effective as the screening tools currently available.

Obamacare is back before the Supreme Court in a challenge to its no-cost coverage requirements for certain preventive health services. The justices will weigh the constitutionality of the US Preventive Services Task Force, which recommends the tests and treatments insurers should cover, when they return to the bench on Monday for the April sitting. If the lower court's decision is upheld, "it is possible, given the posture of the case, that over 150 million Americans lose free coverage of hundreds of benefits," said Sara Rosenbaum, an emerita professor of health law and policy at George Washington University. Rosenbaum joins Cases and Controversies hosts Greg Stohr and Lydia Wheeler to talk about why the case is more about power than it is public health and what's at stake if the court does away with the insurance coverage that's caught in its crosshairs. Do you have feedback on this episode of Cases & Controversies, Give us a call and leave a voicemail at 703-341-3690.

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-425 Overview: In this episode we discuss updates on the treatment and management of obstructive sleep apnea (OSA). This is a common health concern, but it is often underdiagnosed and can have significant health impacts. We review its prevalence and standard treatments, highlighting the recently used medication therapy that has been found to be effective in treating OSA, particularly in individuals with obesity.  Episode resource links: https://www.aafp.org/pubs/afp/issues/2023/0300/uspstf-obstructive-sleep-apnea.html https://emedicine.medscape.com/article/295807-overview Malhotra, A., Grunstein, R. R., Fietze, I., Weaver, T. E., Redline, S., Azarbarzin, A., ... & Bednarik, J. (2024). Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity. New England Journal of Medicine. Mangione, C. M., Barry, M. J., Nicholson, W. K., Cabana, M., Chelmow, D., Coker, T. R., ... & US Preventive Services Task Force. (2022). Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement. Jama, 328(19), 1945-1950. https://aasm.org/rising-prevalence-of-sleep-apnea-in-u-s-threatens-public-health/ Guest: Mariyan L. Montaque, DNP, FNP-BC  Music Credit: Matthew Bugos Thoughts? Suggestions? Email us at FranklySpeaking@pri-med.com  

Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-425 Overview: In this episode we discuss updates on the treatment and management of obstructive sleep apnea (OSA). This is a common health concern, but it is often underdiagnosed and can have significant health impacts. We review its prevalence and standard treatments, highlighting the recently used medication therapy that has been found to be effective in treating OSA, particularly in individuals with obesity.  Episode resource links: https://www.aafp.org/pubs/afp/issues/2023/0300/uspstf-obstructive-sleep-apnea.html https://emedicine.medscape.com/article/295807-overview Malhotra, A., Grunstein, R. R., Fietze, I., Weaver, T. E., Redline, S., Azarbarzin, A., ... & Bednarik, J. (2024). Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity. New England Journal of Medicine. Mangione, C. M., Barry, M. J., Nicholson, W. K., Cabana, M., Chelmow, D., Coker, T. R., ... & US Preventive Services Task Force. (2022). Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement. Jama, 328(19), 1945-1950. https://aasm.org/rising-prevalence-of-sleep-apnea-in-u-s-threatens-public-health/ Guest: Mariyan L. Montaque, DNP, FNP-BC  Music Credit: Matthew Bugos Thoughts? Suggestions? Email us at FranklySpeaking@pri-med.com  

Luigi Mangione is facing several charges – including a rare one – for the killing of UnitedHealthcare's CEO earlier this month. Incoming Senate Majority Leader John Thune has a plan to get the new Congress up and running next month. The suspect in the Gilgo Beach serial killings has been charged with the murder of a seventh victim. The US Preventive Services Task Force may have new recommendations for preventing falls and fractures in older adults. Plus, a 500-year-old British institution is in the process of being sold. Learn more about your ad choices. Visit podcastchoices.com/adchoices

Un nouvel épisode du Pharmascope est disponible et on s'attaque cette fois au trouble d'usage d'alcool. Dans cette première partie, Nicolas, Isabelle et une nouvelle invitée discutent du dépistage et de l'évaluation de cette maladie sous diagnostiquée, en plus de réviser la prise en charge du sevrage alcoolique. Les objectifs pour cet épisode sont: Procéder au dépistage du trouble d'usage d'alcool Diagnostiquer un trouble d'usage d'alcool Discuter des bénéfices et des désavantages associés aux principaux traitements pharmacologiques du sevrage alcoolique Ressources pertinentes en lien avec l'épisode Lignes directrices canadiennes récentes en trouble d'usage d'alcoolWood E, Bright J, Hsu K, et coll. Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder. CMAJ. 2023 Oct 16;195(40):E1364-E1379. Repères canadiens sur l'alcool et la santé : rapport final. Centre canadien sur les dépendances et l'usage de substances. 2023 Guide canadien sur les risques associés à l'usage d'alcoolCoalition canadienne pour la santé mentale des personnes pagées. Lignes directrices sur le trouble lié à l'utilisation de l'alcool chez les personnes âgées. 2023. Guide de l'INESSS sur la prise en charge du trouble d'utilisation d'alcoolINESSS. Sevrage d'alcool et prévention des rechutes. 2021. US Preventive Services Task Force; Curry SJ, Krist AH, Owens DK, et coll. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Nov 13;320(18):1899-1909. Mitchell AJ, Bird V, Rizzo M, et coll. Accuracy of one or two simple questions to identify alcohol-use disorder in primary care: a meta-analysis. Br J Gen Pract. 2014 Jul;64(624):e408-18. Bush K, Kivlahan DR, McDonell MB, et coll. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998 Sep 14;158(16):1789-95. Maldonado JR, Sher Y, Das S, et coll. Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome. Alcohol Alcohol. 2015 Sep;50(5):509-18. Kaner EF, Beyer FR, Muirhead C, et coll. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018 Feb 24;2(2):CD004148. Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD005063. Daeppen JB, Gache P, Landry U, et coll. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002 May 27;162(10):1117-21. Elholm B, Larsen K, Hornnes N, Zierau F, Becker U. Alcohol withdrawal syndrome: symptom-triggered versus fixed-schedule treatment in an outpatient setting. Alcohol Alcohol. 2011 May-Jun;46(3):318-23. Minozzi S, Amato L, Vecchi S, Davoli M. Anticonvulsants for alcohol withdrawal. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD005064. Airagnes G, Valter R, Ducoutumany G, Vansteene C, Trabut JB, Gorwood P, Dubertret C, Matta J, Charles-Nelson A, Limosin F. Magnesium in the treatment of alcohol withdrawal syndrome: a multicenter randomized controlled trial. Alcohol Alcohol. 2023 May 9;58(3):329-335.

Send us a Text Message.We're bombarded with advertisements for all sorts of tests these days: comprehensive blood panels for a few hundred dollars, total body MRI scans for cancer detection, heart calcium scans, and even tests to rule out multiple cancers. But are these tests worth it if you are asymptomatic and don't have an important family history? A few years ago, I experienced fainting episodes while running. After a series of tests, including seeing a cardiologist, I was told that my blood pressure dropped upon standing—a condition that required no treatment, just caution. During these tests, they found that my heart was larger than usual. This discovery led to a lot of anxiety over the years, despite it likely being a false positive. This case illustrates how even with legitimate symptoms, testing can sometimes lead to more questions than answers.  And, large panels of tests compound the problem.The Issues with TestingIt's tempting to think that more testing is better, but the reality is that tests are imperfect. They're often based on statistical averages, and results can be misleading. For example, if you undergo multiple tests, you're likely to get some abnormal results just by chance. This can lead to further testing, expense, time, potential medical complications, and unnecessary worry.Medical Expert RecommendationsOrganizations like the US Preventive Services Task Force and the American College of Radiology provide guidance on screening tests. They recommend specific tests like pap smears, mammograms, and colonoscopies, but not routine total body MRIs or large blood panels. Even well-regarded screening tests can result in false positives, as shown by studies and practices in countries like South Korea.Real-Life ExamplesI've seen friends go through the stress of false positives from MRIs or calcium scores, leading to further tests and anxiety. It's essential to weigh the potential impact of these findings on your life, including how they might affect insurance and your mental well-being.ConclusionTo sum up, while early detection of health issues sounds appealing, the reality is that many screening tests can lead to false positives and unnecessary complications. If you're asymptomatic and don't have a concerning family history, it's often best to save your money and avoid these tests. Always consult with your doctor to make informed decisions based on your specific health needs.

Significant variations in medical treatments, even within the same state, challenge the belief that medical care is primarily based on science. In this episode, Dr. Rita Redberg, a Professor of Medicine at UCSF Health, examines the belief that medical care is based primarily on science by discussing significant variations in treatment practices and advocating for evidence-based medicine. In her "Less is More" series in JAMA Internal Medicine, she aims to improve test readability and effectiveness. Throughout this interview, Dr. Redberg discusses the US Preventive Services Task Force's controversial mammography guidelines and the potential harms of over-testing, underscoring the importance of high-quality, unbiased evidence and rigorous FDA approval processes for new medical devices and drugs. She also addresses issues like unnecessary procedures motivated by fear of litigation or financial incentives and strongly calls for removing conflicts of interest from scientific trials and enhancing NIH funding to promote independent research.  Tune in and learn about the importance of evidence-based practices in health care and the steps needed to ensure safer, more effective patient care! Learn more about your ad choices. Visit megaphone.fm/adchoices

Today's Headlines: Following the Supreme Court's recent ruling against an executive ban on bump stocks, Senate Majority Leader Chuck Schumer attempted to introduce Congressional legislation for a similar ban. However, Senate Republicans blocked the proposal despite having over 20 cosponsors, with Susan Collins of Maine being the sole Republican supporter. Meanwhile, Vladimir Putin and Kim Jong Un have signed an agreement solidifying their alliance, pledging mutual aid in case of aggression and emphasizing trade, security, and cultural ties. On a different front, Iran-backed Houthi rebels attacked a carrier ship in the Red Sea, causing it to sink and killing one person, which has significantly disrupted maritime traffic in the region. Lastly, the US Preventive Services Task Force released new guidelines for healthy eating and exercise for children over six with high BMI, recommending 26 hours of behavior modification but not semaglutide medications, addressing the increasing issue of high BMI among US children. Resources/Articles mentioned in this episode: Axios: Bump stock ban blocked by Senate Republicans AP News: Russia and North Korea sign partnership deal that appears to be the strongest since the Cold War Politico: Ship attacked by Yemen's Houthi rebels in fatal assault sinks in Red Sea CNN: To help children with high BMI, expert panel recommends 26 hours of behavior coaching — but not weight-loss drugs Morning Announcements is produced by Sami Sage alongside Bridget Schwartz and edited by Grace Hernandez-Johnson Learn more about your ad choices. Visit megaphone.fm/adchoices

Amidst rising breast cancer rates among younger Americans, a new guideline about breast cancer screening emerges from the US Preventive Services Task Force. The USPSTF now recommends women beginning at 40 years old should receive a mammogram every other year. The previous recommendation was that women should begin receiving biannual screenings at age 50. Candy O'Terry, radio personality and breast cancer survivor, joined Dan to discuss the new guideline and share her story.Ask Alexa to play WBZ NewsRadio on #iHeartRadio

Episode 161: Depression FundamentalsFuture doctors Madeline Tena and Jane Park define depression and explain different methods to diagnose it. Non-pharmacologic and pharmacologic treatment is mentioned briefly at the end.  Written by Madeline Tena, MSIII, and Jane Park, MSIII. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Per the language of Mental Health, depression can be defined as a mood, a symptom, a syndrome of associated disorders, or a specific mental disorder. As a state of mood, depression is associated with feelings of sadness, despair, emptiness, discouragement, and hopelessness. The sense of having no feelings or appearing tearful can also be a form of depressed mood. A depressed mood also can be a part of a collection of symptoms that explain a syndrome. Depression as a mental disorder can encompass depressive syndromes. Per the American Psychiatric Association DSM-5-TR, depressive disorders commonly include sad, empty, irritable mood, accompanied by changes in one's functional capacity. They can be classified by severity and recurrence, and associated with hypomania, mania, or psychosis. Depressive disorders include major depressive disorder (including major depressive episodes), persistent depressive disorder, premenstrual dysphoric disorder, substance-induced depressive disorder, depressive disorder due to medical condition, other specified depressive disorder, and unspecified depressive disorder.Today, we will cover unipolar depressive disorder, also known as major depressive disorder. MDD.Major depressive disorder is a mood disorder primarily characterized by at least one major depressive episode without manic or hypomanic episodes. Depressive episode is a period of at least 2 weeks of depressed mood or anhedonia in nearly all activities for most of the day nearly every day, with four or more associated symptoms in the same 2 weeks. We will discuss specific symptoms for diagnosis further on. Epidemiology of depression.Nationally or regionally representative surveys in 21 countries estimate that the 12-month prevalence of major depressive disorder across all countries is 5 percent. Furthermore, the prevalence of major depressive disorder plus persistent depressive disorder in developed countries (United States and Europe) is approximately 18 percent. Multiple studies consistently indicate that in the general population of the United States, the average age of onset for unipolar major depression and for persistent depressive disorder (dysthymia) is approximately 30 years old. During 2020, approximately ⅕ US adults have reported receiving a diagnosis by a healthcare provider, with the highest prevalence found among young adults age (18-24 year age… generation Z). Within the US there was considerable geographic variation in the prevalence of depression, with the highest state and county estimates of depression observed along the Appalachian and southern Mississippi Valley regions. Why do we care about depression?Because depression is associated with impaired life quality. It can impair a patient's social, physical, and psychological functioning. Also, depression is associated with mortality. A study done by UPenn Family Practice and Community Medicine in 2005 showed that among older, primary-care patients over a 2-year follow-up interval, depression contributed as much to mortality as did myocardial infarction or diabetes. A prospective study from 2005-2017 that followed 186 patients for up to 38 years further showed that patients with major depressive disorder had 27 times higher incidence rate of suicide than the general population. (1, 2). Also, patients dying by suicide visit primary care physicians more than twice as often as mental health clinicians. It is estimated that 45% of patients who died by suicide saw their primary care physician in the month before their death. Only 20% saw a mental health professional a month before their death. (3)Suicidality in depression.It seems that primary care physicians often do not ask about suicidal symptoms in depressive patients. A 2007 study by Mitchell Feldman at the University of California San Francisco showed that 152 family physicians and internists who participated in a standardized patient with antidepressants, suicide was explored in only 36% of the encounters. (4)Physicians, including primary care physicians, should ask patients with depression about suicidality with questions such as: Do you wish you were dead? In the past few weeks, have you been thinking about killing yourself? Do you have a plan to kill yourself? Have you ever tried to kill yourself? (5) Screening for depression.The USPSTF recommends screening for depression in all adults: 18 years old and over regardless of risk factors. Some factors increase the risk of positive screening, such as temperament (negative affectivity/neuroticism), general medical illness, and family history. First-degree family members of people with MDD have a 2-4 times higher risk of MDD than the general population. Furthermore, social history can increase risk as well: sexual abuse, racism, and other forms of discrimination.It is important to highlight the risk in women because they may also be at risk related to specific reproductive life stages (premenstrual period, postpartum, perimenopause). The USPSTF includes pregnant individuals and patients in the postpartum period to be screened for depression. Screening tools. The US Preventive Services Task Force recommends depression screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years (grade B). Similarly, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) has also recommended annual screening for depression in children aged 12 and older. (6) Some tools used for screening in this age group are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI). For the general adult population, it is recommended that all patients not currently receiving treatment for depression be screened using the Patient Health Questionnaire-2 (PHQ-2) (7)PHQ 2 is a survey scored 0-6. The survey asks two questions: Over the last 2 weeks, how often have you been bothered by any of the following problems?Little interest or pleasure in doing things.Feeling down, depressed, or hopeless.Answers should be given in a numerical rating. 0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day. A score ≥ 3 is considered positive, and a follow-up full clinical assessment is recommended. The PHQ-2 has a sensitivity of 91% and a specificity of 67% when compared to a semi-structured interview. Keep in mind that the PHQ-2 may be slightly less sensitive to older individuals. Individuals who screen positive with PHQ-2 should have additional screening with the PHQ-9, which is a nine-item, self or clinician-administered, brief questionnaire that is specific to depression. (8) Its content maps directly to the DSM-5 criteria for major depression. (9)The PHQ-9 is a set of 9 questions. The answers are scored similarly to PHQ-2, with a numerical scoring between 0 and 3. (0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day). Dr. Arreaza, you will be my patient today, are you ready? It's important that you think about the last 2 weeks.Over the last 2 weeks, how often have you been bothered by any of the following problems?Little interest or pleasure in doing things. [Dr. Arreaza answers, “sometimes”. Jane asks, “is it several days or nearly every day?”. Dr. Arreaza answers, “nearly every day” 3]Feeling down, depressed or hopeless [Dr. Arreaza: every day 3]Trouble falling or staying asleep, or sleeping too much [Dr. Arreaza: not at all 0]Feeling tired or having little energy [Dr. Arreaza: not at all 0]Poor appetite or overeating [Dr. Arreaza: every day 3]Feeling bad about yourself- or that you are a failure or have let yourself or your family down [Dr. Arreaza: several days 1]Trouble concentrating on things, such as reading the newspaper or watching television [Dr. Arreaza: Several days 2]Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. [Dr. Arreaza: Not at all 0]Thoughts that you would be better off dead, or of hurting yourself [Not at all 0]Jane: Your score is 12.Maddy: Regarding severity, a total score of 1-4 suggests minimal depression. 5-9 suggests mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe depression. PHQ-9 with patients' scores over 10 had a specificity of 88% and sensitivity of 88% for MDD. (10)But if there are at least 4 non-zero items, including question #1 or #2, consider a depressive disorder and add up the scores. If there are at least 5 non-zero items including questions #1 or #2, consider major depressive disorder specifically. The questionnaire is the starting point for a conversation about depression.A couple of things to note: 1. Physicians should make sure to verify patient responses given the questionnaire can be self-administered. Diagnosis also requires impairment in the patient's job, social, or other important areas of functioning. 2. Diagnosis requires a ruling-out of normal bereavement, histories of manic episodes, depressive episodes better explained by schizoaffective disorder, any superimposed schizophrenia, a physical disorder, medication, or other biological cause of depressive symptoms.Once a patient is newly diagnosed and/or started on treatment, a regular interval administration (e.g. 2 weeks or at every appointment) of PHQ-9 is recommended. The PHQ-9 has good reliability, validity, and high adaptability for MDD patients in psychiatric hospitals for screening and evaluation of depression severity. (12) Other than PHQ-9, there is also Geriatric Depression Scale-15 for older patients with mini mental status exam (MMSE) that scored over 10. (13)For postpartum depression, the preferred screening tool is the Edinburgh postnatal depression scale[Click here (stanford.edu)].Non-pharmacologic and pharmacologic treatment.Now that we have diagnosed the patient, we have to start management. Patients can consider non-pharmacologic treatment such as lifestyle modifications. This can include sleep hygiene, reduction in drug use, increased social support, regular aerobic exercise, finding time for relaxation, and improved nutrition. Furthermore, based on severity, patients can start psychotherapy alone or psychotherapy + pharmacotherapy. Admission is required for pts with complex/severe depression or suicidality. There should be an assessment of efficacy at 6 weeks.There is a warning about patients aged 18-24 who are at increased risk of suicide when taking SSRI within the first couple weeks of treatment. Mediations: SSRI, SNRI, tricyclic antidepressants, MAOIs, and Atypical antidepressants: including trazodone, mirtazapine (Remeron), bupropion (Wellbutrin SR). More research is being done on psychedelic drugs such as ketamine and psilocybin as possible treatments. There are therapies such as ECT available too.Potential Harm of Tx: Potential harms of pharmacotherapy: -SNRI:  initial increases in anxiety, insomnia, and restlessness, and possible sexual dysfunction and headaches as well. Compared with the SSRI class, the SNRI class tends to induce more nausea, insomnia, dry mouth, and in rare cases hypertension.-Tricyclic: Cause of numerous side effects, very infrequently prescribed unless the patient is not responding to other forms of treatment. Side effects that are included are: dry mouth. slight blurring of vision, constipation, problems passing urine, drowsiness, dizziness,  weight gain, excessive sweating (especially at night). Avoid TCAs in elderly patients.-MAOIS: MAO-IS can cause side effects too, including dizziness or lightheadedness, dry mouth, nausea, diarrhea or constipation, drowsiness, and insomnia. Furthermore, other less common side effects can include involuntary muscle jerks, hypotension, reduced sexual desire/ ability to orgasm, weight gain, difficulty starting urine flow, muscle cramps, and paresthesia.Remember to screen your patients. In case you establish a diagnosis, discuss treatments, including non-pharmacologic and pharmacologic options. Warn your patients about side effects and the timing to see the benefits of the medication, usually after 6 weeks. __________________Conclusion: Now we conclude episode number 161, “Depression Fundamentals.” Future doctors Park and Tena discussed depression and its risk factors, screening, and treatment. They went through the PHQ2 and PHQ9 as screening tools, as well as commonly used treatments and their side effects, such as SSRIs. Dr. Arreaza also highlighted the importance of asking about suicidality in your depressed patients, there is a lot of room for improvement in that aspect. This week we thank Hector Arreaza, Madeline Tena, and Jane Park. Audio editing by Adrianne Silva.Talk_OutroEven without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord. 2002;68(2-3):167-181. doi:10.1016/s0165-0327(01)00377-9. https://pubmed.ncbi.nlm.nih.gov/12063145/Miron O, Yu KH, Wilf-Miron R, Kohane IS. Suicide Rates Among Adolescents and Young Adults in the United States, 2000-2017. JAMA. 2019;321(23):2362-2364. doi:10.1001/jama.2019.5054. https://pubmed.ncbi.nlm.nih.gov/31211337/ Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5(5):412-418. doi:10.1370/afm.719. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000302/.Brief Suicide Safety Assessment,National Institute of Mental Health (NIMH), July 11, 2020. https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/adult-outpatient/bssa_outpatient_adult_asq_nimh_toolkit.pdfBeck A, LeBlanc JC, Morissette K, et al. Screening for depression in children and adolescents: a protocol for a systematic review update. Syst Rev. 2021;10(1):24. Published 2021 Jan 12. doi:10.1186/s13643-020-01568-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802305/Williams, John; Nieuwsma, Jason. Screening for depression in adults, UpToDate, updated on November 30, 2023. https://www.uptodate.com/contents/screening-for-depression-in-adults.Instrument: Patient Health Questionnaire-9 (PHQ-9), National Institute on Drug Abuse, https://cde.nida.nih.gov/instrument/f226b1a0-897c-de2a-e040-bb89ad4338b9.Lowe B, et al. Monitoring depression-treatment outcomes with the Patient Health Questionnaire-9 (PHQ-9). Med Care, 42, 1194-1201, 2004.Sun, Y., Fu, Z., Bo, Q. et al.The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC Psychiatry20, 474 (2020). https://doi.org/10.1186/s12888-020-02885-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/Conradsson M, Rosendahl E, Littbrand H, Gustafson Y, Olofsson B, Lövheim H. Usefulness of the Geriatric Depression Scale 15-item version among very old people with and without cognitive impairment. Aging Ment Health. 2013;17(5):638-645. doi:10.1080/13607863.2012.758231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/.Royalty-free music used for this episode: Old Mexican Sunset by Videvo, downloaded on Nov 06, 2023 from https://www.videvo.net

The history of mammography begins with the discovery of X-rays in 1895. But it took a very long time for breast imaging to advance, in part because it wasn't prioritized.  Research: “The St George's Four: Meet the women that shaped St George's.” St. George's University of London. 3/8/2019. https://www.sgul.ac.uk/news/the-st-george-s-four-meet-the-women-that-shaped-st-george-s American Physical Society. “This Month in Physics History.” November 2001 (Volume 10, Number 10). https://www.aps.org/publications/apsnews/200111/history.cfm Bassett, Lawrence W. and Richard H. Gold. “The Evolution of Mammography.” AJR 150:493-498, March 1988. Bhidé, Amar et al. “Case Histories of Significant Medical Advances: Mammography.” Harvard Business School Working Paper 20-002. 2021. CROWTHER, J. Röntgen Centenary and Fifty Years of X-Rays. Nature 155, 351–353 (1945). https://doi.org/10.1038/155351a0 Davis, Devra. “The Secret History Of Mammography.” HuffPost. 11/17/2011. https://www.huffpost.com/entry/the-secret-history-of-mam_b_364733 Haus, Arthur G. “Historical Technical Developments in Mammography. Technology in Cancer Research & Treatment. ISSN 1533-0346. Volume 1, Number 2, April (2002) Kalaf, José Michael. “Mammography: a history of success and scientific enthusiasm.” Radiol Bras. 2014 Jul/Ago;47(4):VII–VIII. http://dx.doi.org/10.1590/0100-3984.2014.47.4e2 Lerner, Barron H. “'To See Today With the Eyes of Tomorrow: A History of Screening Mammography.'” CBMH/BCMH I Volume 20:2 2003 / p. 299-321. Lerner, Barron H. “Why Was the US Preventive Services Task Force's 2009 Breast Cancer Screening Recommendation So Objectionable? A Historical Analysis.” The Milbank Quarterly, September 2022, Vol. 100, No. 3 (September 2022). https://www.jstor.org/stable/10.2307/48713998 Lienhard, Dina A., "Mammography". Embryo Project Encyclopedia ( 2018-03-25 ). ISSN: 1940-5030 https://hdl.handle.net/10776/13056 Mao X, He W, Humphreys K, et al. Breast Cancer Incidence After a False-Positive Mammography Result. JAMA Oncol. Published online November 02, 2023. doi:10.1001/jamaoncol.2023.4519 Mekasut, Nitida. “Mammography: From Past to Present.” The Bangkok Medical Journal. February 2011. https://www.bangkokmedjournal.com/sites/default/files/fullpapers/2010-1-Mekasut.pdf Nicosia, Luca et al. “History of Mammography: Analysis of Breast Imaging Diagnostic Achievements over the Last Century.” Healthcare 2023, 11, 1596. https://doi.org/10.3390/healthcare11111596 Ritvo, Max. "The Role of Diagnostic Roentgenology in Medicine." New England Journal of Medicine 262, no. 24 (1960): 1201-09. Skloot, Rebecca. “Taboo Organ: How a Pitt Alum Refused to Let Mammography Be Ignored.” Pittmed. April 2001. https://www.pittmed.health.pitt.edu/apr_2001/taboo_organ.pdf Warren, Stafford L. “A Roentgenologic Study of the Breast.” The American Journal of Roentgenology and Radium Therapy 1930-08: Vol 24 Iss 2. Zenger, Ingo. “The history of mammography.” Siemens. https://www.medmuseum.siemens-healthineers.com/en/stories-from-the-museum/history-mammography  See omnystudio.com/listener for privacy information.

In this episode of the Black Health 365 podcast, Jackie and Britt are joined by Dr. Esa Davis, a U.S. Preventive Services Task Force member. Dr. Davis is a professor of medicine and family and community medicine and holds the positions of Associate Vice President for community health and senior dean of population and community medicine at the University of Maryland School of Medicine. During the podcast, Dr. Davis explains the importance of the US Preventive Services Task Force for hypertensive disorders of pregnancy. She shares how screenings can help diagnose hypertensive disorders like preeclampsia and hypertension. The nationwide initiative can assist expectant mothers and decrease the black maternal death rate in our community. Jackie and Britt hope this information will inspire our community to learn about the U.S. Preventative Services Task Force recommendations and seek medical attention sooner during pregnancy. Dr. Esa Davis is a Task Force member and a professor of medicine and family and community medicine, the associate vice president for community health, and the senior associate dean of population and community medicine at the University of Maryland School of Medicine. She is the lead health equity strategist for the University of Maryland Institute for Health Computing. Dr. Davis is also the director of the Transforming Biomedical Research and Academic Faculty Through Leadership Opportunities, Training, and Mentorship (TRANSFORM) program.See omnystudio.com/listener for privacy information.

The US Preventive Services Task Force has recently updated its guidelines for breast cancer screenings to help curb the 42,000yearly deaths. Our experts explain these changes, how to perform at-home exams, and why aggressive breast cancer may no longer be a death sentence. Learn More: https://radiohealthjournal.org/everyone-has-lumps-and-bumps-make-sure-yours-arent-deadly Learn more about your ad choices. Visit podcastchoices.com/adchoices

Brendan speaks with Dr. Joshua Thomas, CEO and Executive Director of the National Alliance on Mental Illness in Delaware and Lynett, who is living with lupus to discuss the connection between physical and mental health for people living with chronic conditions. TRIGGER WARNING: This episode contains mention of self-harm and suicide, which may be triggering to some individuals. If you are in crisis, or you know someone who may be, please contact the 988 Lifeline by dialing 988 or visit 988lifeline.org. Everyone's wellbeing matters.   The National Alliance on Mental Illness (NAMI) is the largest grassroots mental health organization in the US, dedicated to building better lives for the millions of Americans impacted by mental illness. It is an alliance of more than 600 local Affiliates and 49 State Organizations working in communities to raise awareness and provide support and education to those in need. For more information or to access the resources referenced in this episode, please visit NAMI.org. To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

Brendan has a conversation with AstraZeneca's very own Dr. Rachele Berria and Dr. Carlos Doti to talk about the importance of routine preventive medical screenings and the variety of factors that impact the rates at which individuals receive screenings. To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

Brendan speaks with AstraZeneca's very own Chief Sustainability Officer, Pam Cheng, and President of National Academy of Medicine, Dr. Victor Dzau, to discuss the health implications of the climate crisis on the next episode of That's Understandable. At AstraZeneca, we believe our future depends on the interconnection of healthy people, a healthy society and a healthy planet. Click here to learn more about sustainability at AstraZeneca.OR: To learn more about sustainability at AstraZeneca, visit: https://www.astrazeneca.com/sustainability.html. AstraZeneca, in collaboration with the National Academy of Medicine (NAM) and POLITICO Focus, convened a roundtable discussion in June 2023 to identify opportunities to scale public-private action to decarbonize the healthcare sector. Click here to learn more about the National Academy of Medicine's (NAM) Action Collaborative on Decarbonizing the U.S. Health Sector.To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

In this episode of "That's Understandable," Liz Bodin, Vice President, US Respiratory & Immunology, and Mariam Koohdary, Deputy General Counsel, BioPharmaceuticals, join Brendan to shed light on the challenges and triumphs of women in leadership roles within the healthcare industry. They discuss the importance of diversity, the role of mentorship, the drive to innovate and how we can all agree – the struggle is real.To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

In this episode, Brendan brings in Cindy Hoots from AstraZeneca and Deborah DiSanzo, President of Best Buy Health, to discuss how artificial intelligence is changing the face of healthcare. Hear what they have to say about AI-led diagnostics, patient privacy and how the Geek Squad has switched from installing TVs to at-home healthcare. (Yes, that Geek Squad). To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

In a recent development, the US Preventive Services Task Force sounded the alarm about the increasing prevalence of hypertensive disorders among pregnant women. They have advised monitoring blood pressure throughout pregnancy since these disorders have doubled in the last three decades, impacting one in ten pregnancies. Unfortunately, the United States lags in maternal health, bearing a troublingly high maternal mortality rate compared to other countries. While the newly recommended guidelines are undeniably important, it is crucial to delve deeper into the root causes that contribute to this and the growing number of other chronic health problems showing up in pregnancy. On today's episode of On Health, I have the privilege of being joined once again by the remarkable Dr. Neel Shah, a forward-thinking OBGYN and the Chief Medical Officer of Maven Clinic. Together, we delve into the heart of the maternal health crisis, exploring its multifaceted origins, and discuss important new ways of thinking about critical problems. We examine the profound societal challenges that impact maternal health and emphasize the urgent need for and significance of personalized care and the promising role of emerging digital healthcare solutions in supporting pregnant individuals. Furthermore, we address the repercussions of the COVID-19 pandemic, including the impact of forced isolation on maternal health. It is of utmost importance that we continue to raise awareness about maternal health and strive for comprehensive changes that prioritize the well-being of both mothers and babies in this country. By tackling the underlying factors that contribute to these challenges and ensuring access to meaningful care, we can achieve healthier outcomes for all, including the most vulnerable members of society. Dr. Neel and I discuss: COVID-19, lack of labor support, isolation, and other unforeseen obstacles for pregnant people Systemic racism and the impact of weathering on maternal mortality rates Dr. Neel's firsthand experience as a practicing OBGYN during the pandemic The dangers of generalizing and the importance of working directly with pregnant people on their individual needs A breakdown of what pregnant or aspiring pregnant people deserve from the healthcare system The goal of the Maven Clinic app and the potential of digital maternal care options Dr. Neel's perspective on the centering pregnancy model Why Dr. Neel feels that competence, reliability, and affirmation are required to move the needle in creating systemic change in maternal care Thank you so much for taking the time to tune in to your body, yourself, and this podcast! Please share the love by sending this to someone in your life who could benefit from the kinds of things we talk about in this space. Make sure to follow your host on Instagram @dr.avivaromm and go to avivaromm.com to join the conversation. Follow Dr. Neel @neel_t_shah, check out the Maven Clinic App and more @mavenclinic

In this episode, Brendan sits down with Dr. Tonya Villafana, Vice President, Global Franchise Head of Infectious Disease at AstraZeneca, to talk about the impact science has on public health. Tonya speaks about the process, the ripple effect of science, the early stages of modern medicine, and the reason why “Talking Heads” is on her pre-meeting playlist. To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

Today's Headlines: Former President Donald Trump has been found liable for sexual abuse and defamation in the New York state civil trial, and has been ordered to pay $5 million to E. Jean Carroll. New York Representative George Santos has been charged with a crime, but the charges are not yet known. Congress failed to reach a deal on the debt ceiling crisis, and President Biden has floated the idea of invoking the 14th Amendment. A bill to raise the age to buy an AR-15 style rifle from 18 to 21 has been advanced in Texas. The US Preventive Services Task Force now recommends women start getting mammograms to detect breast cancer at age 40. Resources/Articles mentioned in this episode: AP News: Jury finds Trump liable for sexual abuse, awards accuser $5M  Washington Post: Rep. George Santos charged by federal prosecutors, people familiar say  NBC News: Biden and McCarthy barely speak, dimming prospects for a debt ceiling deal Texas Standard: In surprise vote, Texas House committee advances bill to raise minimum age to buy assault rifles  Axios: Women should start getting mammograms at 40 not 50, major health panel says US Preventative Task Force: Breast Cancer: Screening  Morning Announcements is produced by Sami Sage alongside Amanda Duberman and Bridget Schwartz

Discovery leads to innovation. Innovation usually leads to changes in processes. But that doesn't always equate to better. Or not necessarily as a replacement.You may have seen a commercial or two for a commercial product where a walking and talking white box depicts the ease and comfort for checking for colorectal cancer at home. The insinuation is that anyone can simply send in a sample of their “#2” and find out if they have anything to worry about regarding cancer in the lower gastrointestinal tract.But at what cost is this substitute for the gold standard of colonoscopy screening actually to the patient? What are the accuracy comparisons? What to make of a positive or negative result?Ken & Eric dive in and discuss the commercial pitch for this method of using fecal DNA vs visual inspection of the colon and what actually might be overlooked for the unsuspecting patient who is trying to remain healthy.Join us on RUMBLE & LOCALS for RAW GCP! USE code GCPFREE for a month of FREE RAWHttps://kbmdhealth.com/rawHttps://kbmdhealth.com/rumbleBonus Notes covered in this episode:Does Cologuard detect polyps?Yes, Cologuard can detect polyps.  However, the detection of large polyps (the precursors to colon cancer) is less than half as accurate as a colonoscopy.Is the Cologuard test as effective as a colonoscopy?No, the Cologuard test is not as effective as a colonoscopy.  Detecting and removing polyps is critical to colon cancer prevention, and Cologuard only detects large precancerous polyps 42% of the time.  A colonoscopy detects the same polyps 95% of the time and they are removed during the same procedure.What does Cologuard detect?Cologuard can detect 92% of cancers and 42% of large precancerous polyps, the precursor to colon cancer.What does it mean if your Cologuard test is positive?If the Cologuard test is positive, it may mean that colon cancer or polyps are present. After a positive Cologuard test a colonoscopy is required for a definitive answer.  The Cologuard test has a 13% false-positive rate, which means 1 in 10 positive tests will incorrectly identify cancer or polyps.Does Cologuard detect cancer?Yes, the Cologuard test can detect cancer 92% of the time.  However, prevention of colon cancer is better than identifying it once you have it.  The best way to prevent colon cancer is by identifying and removing precancerous polyps that don't turn into cancer later.  Cologuard only finds 42% of large, dangerous polyps that can turn into colon cancer.Can patients use Cologuard instead of a colonoscopy?Cologuard is not designed to be a replacement for a colonoscopy, even though advertisements may suggest otherwise.  58% of the time, dangerous precancerous polyps are not detected with Cologuard, which is significantly less effective than a colonoscopy. However, Cologuard may be an option for some patients who insist on not getting a colonoscopy or those not healthy enough to have a colonoscopy.  Even a 42% chance of detection is better than no detection at all.References for this episode:Uptodate.com- colon cancer screening guidelinesItzkowitz SH, Ahlquist DA. The case for a multitarget stool DNA test: a closer look at the cost effectiveness model. Gastroenterology. 2017;152(6):1620–1621Johnson DH, Kisiel JB, Burger KN, et al. Multitarget stool DNA test: clinical performance and impact on yield and quality of colonoscopy for colorectal cancer screening. Gastrointest Endosc. 2017;85(3):657–665.e1.Zauber A, Knudsen A, Rutter CM, et al. Evaluating the Benefits and Harms of Colorectal Cancer Screening Strategies: A Collaborative Modeling Approach. AHRQ Publication No. 14-05203-EF-2. Rockville, MD: Agency for Healthcare Research and Quality; October 2015.Knudsen AB, Zauber AG, Rutter CM, et al. Estimation of Benefits, Burden, and Harms of Colorectal Cancer Screening Strategies: Modeling Study for the US Preventive Services Task Force. JAMA 2016; 315:2595.Cost-effectiveness of a multitarget stool DNA test for colorectal cancer screening of Medicare beneficiaries Steffie K. Naber  ,Amy B. Knudsen ,Ann G. Zauber,Carolyn M. Rutter,Sara E. Fischer,Chester J. Pabiniak,Brittany Soto,Karen M. Kuntz,Iris Lansdorp-VogelaarRex DK, Boland CR, et al. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. GI Endosc. 2017; 86(1):18-33.

Brendan invites Brittany to tell her story to help the audience understand what it means to be immunocompromised. ​​Episode 3 will serve as a human-interest piece and dive into how Brittany coped with her diagnosis, how it changed her life and how the pandemic further complicated her daily living. ​To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

https://302.buzz/PM-WhatAreYourThoughtsAggression in children is a complex issue that can leave parents feeling helpless and desperate for a solution. Many turn to medication as a quick fix, but according to Dr. Lia Gaggino's guest, Dr. Peter Jensen, multiple medications are not always the answer. It's important to assess the situation correctly and consider alternative approaches before turning to medication. In this episode, Doctors Gaggino and Jensen explore the various causes of aggression in children and provide tips on how to handle it effectively without resorting to excessive medication. Whether you're a parent, caregiver, or educator, the information provided in this episode can help you better understand aggression in children and how best to support them. Get your pad and pencils ready, you'll be taking notes on this one. [00:30 -27:46] Understanding the Different Types of Aggression in Children and How to Treat ThemThe Importance of Assessing and Diagnosing before Prescribing MedicationAggression in children can fall into different categories, such as chronically irritable and explosive or misinterpreting social cuesDiagnostic Skills Help in Identifying the Underlying Causes of Aggressive Behaviors in ChildrenBipolar disorder and schizophrenia are unlikely causes of aggressive behavior in children[27:47- 38:02] Understanding and Treating Aggressive Behaviors in Children Treatment for ADHD should be maximized before turning to other medicationsResperidone and Aripiprazole have been approved by the FDA to treat aggression in childrenPrimary care providers need to get comfortable with atypical medications Guidelines for treating maladaptive aggression in youth are available in the journal Pediatrics[38:03 -48:14] Evaluating Medication for Children with Mental Health DisordersTrauma should be considered when treating children with psychiatric medications.Avoid the "pharmacotherapy of desperation," which involves adding multiple medications without clear rationale. Deprescribing, or slowly decreasing medication use, can be helpful for children on multiple medications that may not be effective.A thorough evaluation of the underlying disorder, using rating scales and input from multiple sources, is essential for choosing the right medication.[48:15 - 57:06] Top Screening Tools for Child Mental HealthVanderbilt Rating Scale is essential for monitoring ADHD in kids on stimulantsPHQ-9 is a quick and free depression scale that is recommended by the US Preventive Services Task Force and Academy of PediatricsSCARED is an effective tool for tracking and screening anxiety in children and can be given to parents or youthPSC-17 is ideal for well-child visits as it has only 17 items and screens for inattention, ADHD, anxiety, and depressionSuicide specific tools like ASK Screening Questions and Columbia should be used alongside PHQ-9 for better screening of suicidal ideation and behavior; CRAFFT can be used to screen for substance use in teenagers. [57:07 - 1:04:54] Closing segment TakeawayYou can reach Dr. Peter JensenWebsite: https://thereachinstitute.org/LinkedIn:

Greed should not be a factor in patient care, and yet more and more it seems to be. Dr. Donald Berwick has a wonderful article titled Salve Lucrum in JAMA, and I highly recommend it. He touches on how his father inspired and inspires him, the importance of community and connection, and the small steps we can take to fight greed. Dr. Donald M. Berwick, MD, MPP, FRCP, is President Emeritus and Senior Fellow at the Institute for Healthcare Improvement. He is former Administrator of the Centers for Medicare & Medicaid Services. Trained as a pediatrician by background, he has taught at Harvard Medical School and Harvard School of Public Health, and he has served on the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. He was Vice Chair of the US Preventive Services Task Force, the first "independent member" of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality, and the Institute of Medicine. Recognized as a leading authority on health care quality and improvement, Dr. Berwick has received numerous awards for his contributions, including from the British National Health Service in 2005, when he was appointed "Honorary Knight Commander of the British Empire" by Her Majesty, Queen Elizabeth II. Dr. Berwick is the author or co-author of over 160 scientific articles and six books. He currently serves as lecturer in the Department of Health Care Policy at Harvard Medical School.  He has a new podcast in spring, 2023 called Turn on the Lights.

Un nouvel épisode du Pharmascope est maintenant disponible! Dans de ce 113ème épisode, Sébastien, Nicolas et Isabelle débutent une série d'épisodes sur l'ostéoporose. Dans ce premier épisode, on aborde le dépistage, l'évaluation et le diagnostic de l'ostéoporose, une maladie qui n'en est peut-être pas vraiment une…   Les objectifs pour cet épisode sont les suivants: Définir l'ostéoporose Identifier les patients nécessitant un dépistage de l'ostéoporose Expliquer les avantages et les limites d'une ostéodensitométrie Évaluer le risque de fracture d'un patient Ressources pertinentes en lien avec l'épisode National Institute for Health and Care Excellence (NICE). Osteoporosis: assessing the risk of fragility fracture. London; 2017. US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:2521-31. Viswanathan M et coll. Screening to Prevent Osteoporotic Fractures: An Evidence Review for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018. (Evidence Synthesis, No. 162. Papaioannou A et coll. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010;182:1864-73. Korownyk C, McCormack J, Allan GM. Who should receive bone mineral density testing? Can Fam Physician. 2015;61:612. Choisir avec soin. L'ostéodensitométrie. Canada. Management of Osteoporosis in Postmenopausal Women: The 2021 Position Statement of The North American Menopause Society'' Editorial Panel. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021;28:973-97. Calculateur FRAXCentre for Metabolic Bone Diseases. FRAX: Fracture Risk Assessment Tool. University of Sheffield, UK.

In this episode, Brendan is joined by AstraZeneca's VP of US Corporate and Government Affairs, Christie Bloomquist, and Tulane University's Dr. Thomas LaVeist to discuss health equity. The trio chat about navigating the healthcare system, the roots of health disparity, how organizations can help, Star Trek, romance novels, and Brendan's sweet dreams.  To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

Our healthcare system is always evolving and changing—which means that doctor's recommendations are too. It's important to stay on top of these to keep our body in tip top shape, particularly as we get older.Dr. Michael Berry is the Vice Chair of the US Preventative Services Task Force and a leading authority on health and aging. He is a board-certified family and preventive medicine physician, with training in integrative medicine, and specializes in primary care. Dr. Berry has dedicated his career to helping people understand how to improve their health and wellbeing through preventive measures. He has been a guest lecturer at medical conferences, a featured speaker on podcasts, and a contributing author to medical publications. Dr. Berry has an extensive background in preventive services, with a particular focus on the latest health recommendations for aging. He has been a part of the US Preventive Services Task Force since 2008, and currently serves as its Vice Chair. He is passionate about helping people practice preventive medicine and live longer, healthier lives. On today's episode, Dr. Berry explains the importance of aspirin for people between the ages of 40 and 59 (and why those over the age of 60 should not start taking it), he explains the importance of lung cancer screening, colon cancer screening and much more.What's Next?What are your views, comments or questions on changing medical recommendations?  Share them with us at info@seniorityauthority.org!  Stay ConnectedGet in touch with our host Cathleen Toomey on LinkedInYou can also find Seniority Authority on Facebook, on Instagram, or you can connect with us on our website!Subscribe to our show on Apple Podcasts, Spotify, or anywhere you get your podcasts.

To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

To learn which screenings are appropriate for you, we encourage you to visit the US Preventive Services Task Force. The US Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services and prolong life.

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!The American Academy of Pediatrics has put out a new Clinical Guideline for the care of higher-weight children. This document is 100 pages long including references and there are so many things that are concerning and dangerous in it that I had trouble deciding how to divide it up to write about it. I began on Thursday with a piece about the undisclosed conflicts of interest. Ultimately for today, I decided to focus on what I think will do the most harm in the guidelines, which is the recommendations for body size manipulation of toddlers, children, and adolescents through intensive behavioral interventions, drugs, and surgeries.A few things before we dive in. First, this piece is long. Really long. I thought about breaking it up to make it easier to parse, but I also know that people are (rightly) very concerned about these guidelines and I didn't want to trickle information/commentary out over days and weeks in case it might be helpful to someone now. Also, know that this may be emotionally difficult to read, in particular for those who have been harmed by weight loss interventions foisted on them as children. That will likely be exacerbated by the gaslighting these guidelines do to erase the lived experience of harm and trauma from the “interventions” they are recommending, and from their co-option of anti-weight-stigma language to promote weight loss. So please take care of yourself, you can always take a break and come back. Per my usual policy I will not link to studies that are based in weight bias and the weight loss paradigm, but will provide enough information for you to Google if you want to read them. I'll also use an asterisk in “ob*sity” for the reasons I explain in the post footer. Ok, big breath and let's get into this.In later newsletters, I'll address other issues in depth, but for now here are some quick thoughts and links about overarching issues before I dig into the actual recommendation:The claim that “ob*sity is a chronic disease—similar to asthma and diabetes”No, it's really not. And it's this faulty premise (that having a body of a certain size is the same thing as having a health condition with actual identifiable symptomology) that underlies everything in these guidelines. The diagnosis of asthma requires documentation of signs or symptoms of airflow obstruction, reversibility of obstruction (improvement in these signs or symptoms with asthma therapy) and no clinical suspicion of an alternative diagnosis. The diagnosis of diabetes requires a glycated hemoglobin (A1C) level of 6.5% or higher. But to diagnose “ob*sity” you just need a scale and a measuring tape. A group of people with this “diagnosis” don't have to share any symptoms at all, they simply have to exist in their bodies. That is not the same as asthma or diabetes, though the weight loss industry (in particular pharmaceutical companies and weight loss surgery interests) have absolutely poured money into campaigns to try to convince us that it is. (Note that the argument that ob*sity is correlated with other health conditions and thus is a disease actually proves the fallacy since some kids/people who are “diagnosed” with “ob*sity” don't have any of those health conditions and some kids/people who are thin do have them. It's especially disingenuous as it ignores the confounding variables of weight stigma and, in particular, weight cycling both of which these guidelines, if adopted, are very likely to increase.)The myth of “non-stigmatizing ob*sity care” Like so much of these guidelines, this idea and much of the verbiage around it mirrors that of the weight loss industry. In this case, it's attempt to co-opt the language of anti-weight-stigma in order to promote (and profit from) weight loss (there's a guide to telling the difference between true anti-stigma work and diet industry propaganda here!) In truth, there is no such thing as non-stigmatizing care for ob*sity, because the concept of ob*sity is rooted in size and the treatment is changing size (the word was made up to pathologize larger bodies, based on a latin root that literally means to eat until fat so…less science than stereotype there.) There is no shame in having a disease, it's just that existing while fat isn't one. The concept of “ob*sity” as a “disease” pathologizes someone's body size. The concept of ob*sity says that your body itself is wrong, and requires intensive therapy and/or risky drugs and surgeries so that it can be/look right. There is no way to say that without engaging in weight stigma.If someone claims that the treatment is actually about health and not size, then it's not “ob*sity” treatment since both the criteria for the “disease” and the measure of successful “treatment” of ob*sity are based on body size. If the treatment is about health and not size, then the treatment and measures of success should be about actual metabolic health, not body size (which would be ethical, evidence-based, weight-neutral care.)The idea that “It is important to recognize that treatment of ob*sity is integral to the treatment of its comorbidities and overw*ight or ob*sity and comorbidities should be treated concurrently”Again, I think this is demonstrably untrue. Any health issues that are considered “comorbidities” of being higher-weight are also health issues that thin people get, which means that they have independent treatments. We could skip body size manipulation attempts entirely and still treat any health issues that a higher-weight child/adolescent has.The dubious claim that “ob*sity treatment” is compatible with eating disorders preventionI wrote a specific piece about this here. Weight loss as a “solution” to weight stigmaThis is unconscionable. Regardless of what someone believes about weight and health, the message that children (as young as 2!) should solve stigma by undertaking intensive and dangerous interventions that risk quality of life moves beyond inappropriate to disgusting, especially when one is perpetuating weight stigma, as these guidelines (and the weight loss industry talking points that are repeated herein) do.There is so much more to unpack here, but I want to move into a discussion of the recommendations themselves.For this, I will start where I left off on the conflict of interest piece. Which is to say, almost all of the authors of these guidelines are firmly entrenched in the body-size-as-disease paradigm. They have pinned their careers to it. None of the authors are coming from a weight-neutral paradigm.  In fact, in the research evaluation methodology section, they explain that they excluded studies that looked at impacting health, rather than weight. In their own words:The primary aim of the intervention studies had to be examination of an ob*sity prevention (intended for children of any weight status) or treatment (intended for children with overw*ight or ob*sity) intervention. The primary intended outcome had to be ob*sity, broadly defined, and not an ob*sity comorbidity.Note that by “ob*sity comorbidity” they mean a health condition that happens to children of all sizes.I don't know if it was intentional, or just a myopic focus on body size manipulation as a supposed healthcare intervention, but the option to focus on health rather than size was specifically excluded by a group of authors whose careers on based on focusing on size.There are three main areas of their recommendation that I'll talk about today - Intensive Health Behavior and Lifestyle Treatment, Weight Loss Drugs, and Weight Loss Surgeries.RECOMMENDATION:  Intensive Health Behavior and Lifestyle Treatment (IHBLT)This is recommended starting as young as age two. That's right, they are recommending intensive interventions to kids in diapers (and they think that they should look into how to “diagnose” kids who are even younger, yikes!) What these guidelines subtly admit is that these interventions don't actually work. They include this (long-time weight loss industry) talking point “a life course approach to identification and treatment should begin as early as possible and continue longitudinally through childhood, adolescence, and young adulthood, with transition into adult care.”The translation to this is that they have absolutely no idea how to make higher-weight people of any age thin long-term. They are aware (and if not they are negligent) that a century of data shows that the vast majority of people will lose weight short-term and gain it back long-term. What they seem to be trying to do here is rebrand yo-yo dieting (aka weight-cycling) as a successful intervention. If there is a prize for moving the goalpost and declaring victory, they are in the running.Don't just take my word for it, they created a graphic as part of Figure 1 to show it:Pro tip: When they say “relapsing remitting” they mean “yo-yo dieting". I know why the weight loss industry loves this idea - it's how they've built a business that creates exponential growth with a product that doesn't work. What I don't understand is how this group of authors can possibly justify this ethically. The health risks of weight cycling are documented (and very consistent with the health risks that get blamed on higher-weight bodies) so setting people up for weight cycling starting as toddlers does not, to me, have the ring of sound science or ethical, evidence-based medicine.Let's dig into the evidence they are using to support this:The guidelines claim that “IHBLT is the foundational approach to achieve body mass reduction or the attenuation of excessive weight gain in children. It involves visits of sufficient frequency and intensity to facilitate sustained healthier eating and physical activity habits.” The study they cite to back this up (Grossman et al; 2017, Screening for ob*sity in children and adolescents: US Preventive Services Task Force recommendation statement) says “Comprehensive, intensive behavioral interventions (≥26 contact hours) in children and adolescents 6 years and older who have ob*sity can result in improvements in weight status for up to 12 months.”They also include a chart of seven randomized controlled trials (RCTs) from 2005-2017. The combined study population of all seven studies was just 1,153 kids. The largest study (with 549 participants) and the only study to include children from ages 2 to 5 had a duration of 12 months and showed a BMI change of 0.42 that year, and was only “effective” (if you consider a .42 change in a year “effective”) in kids ages 4-8 years old. There was only one study that followed up for more than 12 months, and from 12 months to 24 months, the BMI change decreased (from 3.3 to 2.8,) consistent with the weight regain pattern that we would expect.This will be a running theme in these guidelines - short-term studies will be used to justify life-long recommendations, and weight regain is ignored. In general, sometimes this is based on the idea that if a weight loss intervention works short-term, then it will continue to work forever, other times it's based on the idea that weight cycling is an ethical, evidence-based healthcare intervention. Again, the data on both the long-term failure of weight loss and the danger of weight cycling does not support this.They make a point to mention that IHBLT “involves interaction with pediatricians and other PHCPs who are trained in lifestyle-related fields and requires significantly more time and resources than are typically allocated to routine well-child care.” At this point I'll note that many of the authors of the guidelines run clinics or have practices that provide exactly this type of care.Their criteria for the studies was, I'll just call it lax: “Over a 3-12 month period: The criteria for the evidence review required a weight-specific outcome at least 3 months after the intervention started.” Obviously, this is a very short-term requirement and, again, excludes studies that looked at actual health instead of just body size.Here again they tell on themselvesTreatments with duration longer than 12 months are likely to have additional and sustained treatment benefit. There is limited evidence, however, to evaluate the durability of effectiveness and the ability of long-term treatments to retain family engagement.Note that the idea that longer duration treatment is “likely” to have additional and sustained treatment benefit is not remotely an evidence-based statement, and I would argue that it is biased and should not be included here. Also, they seem to be setting the stage for blaming families for the entirely predictable and almost always inevitable weight regain.Under “referral strategies” they get real about how little weight loss we're actually talking about:Pediatricians and other Primary Healthcare Providers (PHCP's) are encouraged to help to set reasonable expectations for these [BMI-based] outcomes among families, as there is a significant heterogeneity to treatment response and there is currently no evidence to predict how individual children will respond. Many children will not experience BMI improvement, particularly if their participation falls below the treatment threshold.”As described in the Health Behavior and Lifestyle Treatment section, those who do experience BMI improvement will likely note a modest improvement of 1% to 3% BMI percentile decline.So they are recommending an “intensive,” time-consuming, expensive intervention to kids starting as young as age 2 with no prognostics as to which kids might be “successful,” the stated result of which is that “many” (their word) of them won't experience any change in the primary outcome, those who do will see a very small change.They do mention the supposed actual health benefits of these interventions, but fail to mention that the health benefits may have nothing to do with the very small change in size. That's because often when health changes and weight changes (at least temporarily) follow behavior change, those who are invested in the weight loss paradigm (financially, clinically, or both) are quick to credit the weight change, rather than the behavior change, for the health change. Here again, the evidence does not support this. It's very possible that these same health improvements could be achieved with absolutely no focus or attention paid to weight, which would provide more benefits and less risks (including the risks associated with both weight stigma and weight cycling.) It could also allow the children (some, remember, still in diapers) to create healthy relationships with food and movement, rather than seeing choices around food and movement as punishment for their size or a way to manipulate it.As they move into specific recommendations, they start with:Despite the lack of evidence for specific strategies on weight outcomes many of these strategies have clear health benefits and were components in RCTs of intensive behavioral intervention. Many strategies are endorsed by major professional or public health organizations. Therefore, pediatricians and other PHCPs can appropriately encourage families to adopt these strategies. To me this sounds a lot like throwing the concept of “evidence-based” right out the window. None of this means “these strategies are likely to lead to long-term weight loss,” but I'll bet that won't be what is conveyed to the patients and families upon whom these “strategies” are foisted. Before we move on to their recommendations around diet drugs, here is some research to contextualize these recommendations:Neumark-Sztainer et. al, 2012, Dieting and unhealthy weight control behaviors during adolescence: Associations with 10-year changes in body mass indexNone of the behaviors being used by adolescents for weight-control purposes predicted weight lossOf greater concern were the negative outcomes associated with dieting and the use of unhealthful weight-control behaviors…including eating disorders and weight gain [Note: This is not to say that there is anything wrong with higher-weight, but that there is something wrong with a supposed healthcare intervention that has significant risks, almost never works, and has the opposite of the intended effect up to 66% of the time.] Raffoul and Williams, 2021, Integrating Health at Every Size principles into adolescent careCurrent weight-focused interventions have not demonstrated any lasting impact on overall adolescent healthBEAT UK, 2020 Eating Disorders Association, Changes Needed to Government Anti-ob*sity StrategiesGovernment-sanctioned anti-ob*sity campaigns* increase the vulnerability of those at risk of developing an eating disorder* exacerbate eating disorder symptoms in those already diagnosed with an eating disorder* show little success at reducing ob*sityStrategies including changes to menus and food labels, information around ‘healthy/unhealthy' foods, and school-based weight management programs all pose a risk.Pinhas et. al. 2013, Trading health for a healthy weight: the uncharted side of healthy weights initiativesOb*sity-prevention programs that push “healthy eating” are triggering disordered eating in some children, creating sudden neuroses around food in children who never before worried about their weightThey were all affected by the idea of trying to adopt a more healthy lifestyle, in the absence of significant pre-existing notions, beliefs or concerns regarding their own weight, shape or eating habits prior to the interventionFiona Willer, Phd, AdvAPD, FHEA, MAICD, Non-Executive Board Director at Dietitians AustraliaQuoted from: health.usnews.com/health-news/blogs/eat-run/articles/for-healthy-kids-skip-the-kurbo-app“Dieting to a weight goal was found to be related to poorer dietary quality, poorer mental health and poorer quality of life when compared with people who were health conscious but not weight conscious”Ok. Moving on.RECOMMENDATION: Use of Pharmacotherapy (aka Weight Loss Drugs)Their consensus recommendation is that pediatricians and other PCHPs “may offer children ages 8 through 11 years of age with ob*sity weight loss pharmacotherapy, according to medication indications, risks, and benefits as an adjunct to health behavior and lifestyle treatment.”They admit that “For children younger than 12 years, there is insufficient evidence to provide a Key Action Statement (KAS) for use of pharmacotherapy for the sole indication of ob*sity,” but then go on to suggest that if kids 8-11 also have other health conditions, somehow weight loss drugs (which are not indicated for the treatment of the actual health conditions they have) “may be indicated.”Their KAS is that “pediatricians and other PHCPs should offer adolescents 12 y and older with ob*sity weight loss pharmacotherapy, according to medication indications, risks and benefits as and adjunct  to health behavior and lifestyle treatment.”The studies that were actually included in the evidence review predominantly studied metformin (alone and in combination with other drugs,) which is not approved for weight loss, orlistat, exenatide, and one study that looked at phentermine, mixed carotenoids, topiramate, ephedrine, and recombinant human growth hormone.Even though the studies for other drugs did not exist at the time of the evidence review, they made the choice to include them anyway. (This includes Wegovy, the drug that Novo Nordisk, a donor to the AAP, has promised their shareholders will be a blockbuster and that announced its approval in children as young as 12 just days prior to the publication of the guidelines.) Let's look at the efficacy of the drugs they are recommending:MetforminAdverse effects include bloating, nausea, flatulence, and diarrhea and lactic acidosis which they characterize as “serious but very rare.” The guidelines describe the evidence of metformin for weight loss in pediatric populations as “conflicting” They evaluated 16 studies, about two-thirds of which showed a “modest BMI reduction” and one-third showed “no benefit.” Also, this drug is not approved for weight loss. They recommend that due to the “modest and inconsistent effectiveness, metformin may be considered as an adjunct to intensive health behavior and lifestyle treatment (IHBLT) and when other indications for use of metformin are present.”Orlistat:This drug is currently approved for ages 12 and up. Orlistat is sold under the name alli by GlaxoSmithKline and as Xenical by Genentech (both GlaxoSmithKline and Genentech are donors to the AAP.) The guidelines point out that the side effects (including fecal urgency, flatulence and oily stool) “greatly limit tolerability” but do say that “Orlistat is FDA approved for long-term treatment of ob*sity in children 12 years and older.” They cite two studies from 2005. One (Behzat et al., Addition of orlistat to conventional treatment in adolescents with severe ob*sity) started with 22 adolescents, 7 of whom dropped out within the first month due to drug side effects. The remaining 15 subjects were followed for 5-15 months with an average of 11.7 months of follow up. Those 15 patients lost 6.27 +/- 5.4 kg within the study time.The other (Chanoine JP et al, 2005, Effect of orlistat on weight and body composition in ob*se adolescents) was a one-year study with 357 adolescents (age 12-15) in the Orlistat group. They lost weight initially but the weight loss stopped at week 12 and by the end of the study the weight of those in the Orlistat group had increased by .53kg.Glucagon-like peptide-1 receptor agonistsThese are drugs that are type 2 diabetes medications that were found to have a side effect of weight loss. In some cases they have been rebranded specifically for weight loss and, in others, are prescribed off-label.ExenatideThis drug is currently approved in kids ages 10 to 17 years of age. The guidelines point out that a small weight loss was shown in two small studies but with “significant adverse effects.”LiraglutideThe study they cite for liraglutide (Kelly et al, Trial Investigators. A randomized, controlled trial of liraglutide for adolescents with ob*sity.) was a 56 week study with a 26-week follow-up period. Participants lost weight initially, but after 42 weeks began to regain weight (though they were still on the drug) at 56 weeks weight gain became more rapid and at the end of the 26-week follow up they were nearing baseline. The guidelines characterize this as “A recent randomized controlled trial found liraglutide (daily injection) more effective than placebo in weight loss at 1 year among patients 12 years and older with ob*sity who did not respond to lifestyle treatment.” They do not make it clear that participants experienced near total weight regain (see graphic below.) In addition to the near total lack of weight loss (and remember that it's pretty likely that subjects continued to regain weight after the tracking stopped at 82 weeks,) side effects included nausea and vomiting, and among patients with a family history of multiple endocrine neoplasia, a slightly increased risk of medullary thyroid cancer. Liraglutide is sold as Victoza and Saxenda by Novo Nordisk. This study was a clinical trial funded by Novo Nordisk, multiple study authors work for, are employees of, take payments from and/or own stock in Novo Nordisk (see disclosures below) and Novo Nordisk provides funding directly to the American Academy of Pediatrics, and has paid thousands of dollars to authors of these guidelines.Just for funsies I checked the disclosures: Dr. Kelly reports receiving donated drugs from AstraZeneca and travel support from Novo Nordisk and serving as an unpaid consultant for Novo Nordisk, Orexigen Therapeutics, VIVUS, and WW (formerly Weight Watchers); Dr. Auerbach, being employed by and owning stock in Novo Nordisk; Dr. Barrientos-Perez, receiving advisory-board fees from Novo Nordisk; Dr. Gies, receiving advisory-board fees from Novo Nordisk; Dr. Hale, being employed by and owning stock in Novo Nordisk; Dr. Marcus, receiving consulting fees from Itrim and owning stock in Health Support Sweden; Dr. Mastrandrea, receiving grant support from AstraZeneca and Sanofi US and grant support and fees for serving on a writing group from Novo Nordisk; Ms. Prabhu, being employed by and owning stock in Novo Nordisk; and Dr. Arslanian, receiving fees for serving on a data monitoring committee from AstraZeneca, fees for serving on a data and safety monitoring board from Boehringer Ingelheim, grant support, paid to University of Pittsburgh, and advisory-board fees from Eli Lilly and Novo Nordisk, and consulting fees from Rhythm Pharmaceuticals. Melanocortin 4 receptor (MC4R) agonistsThese are specialty drugs that are only FDA approved for patients 6 years and older with proopiomelanocortin deficiency, proprotein subtilisin or kexin type 1 deficiency and leptin receptor deficiency confirmed by genetic testing. They site a small, uncontrolled study in which patients experience weight loss of 12-25% over 1 year. PhenterminePhentermine is a controlled substance chemically similar to amphetamine which carries a risk of dependence as well as side effects including elevated blood pressure, dizziness, and tremor. These are FDA approved for a 3-month course of therapy for adolescents 16 or older. I'm not clear what good could come out of giving a teenager a drug with these kinds of risk for 3 months?TopiramateThis is a drug that is used to treat seizures and migraines that happens to have a side effect of making people not want to eat through what the guidelines admit are “largely unknown mechanisms.” These drugs cause cognitive slowing and can cause embryo malformation. It's approved for children 2 years and older with epilepsy and 6 and older for headaches and I cannot for the life of me imagine how it could possibly be ethical to cause cognitive slowing in a child (who is going to school!) in order to disrupt their bodies hunger signals.Phentermine/TopiramateYou read that right, those last two drugs with the dangerous, quality-of-life impacting side effects? The guidelines discuss the option of prescribing them together. To children. This is based on a 56-week study (Kelly et al, 2022, Phentermine/topiramate for the treatment of adolescent ob*sity.) In the study, 54 subjects were given a mild dose, 15 of them dropped out. 113 were given the “top dose” 44 of them dropped out. As we've seen in other studies, weight loss had leveled off and begun to rise slightly by week 56 and there is no reason to believe it wouldn't go back up, but we'll never know because they didn't do any more follow-up. By the way, like most of the other studies, these subjects were also undergoing a “lifestyle modification program.” Also, like the other drugs, I think it's important to note that this was FDA-approved for “chronic treatment” based on the results of a study that only lasted 56 weeks. That is a common situation with weight loss drugs.Finally, the guidelines don't mention that side effects of this drug include increased heart rate, suicidal behavior and ideation, slowing of linear growth, acute myopia, secondary angle closure glaucoma, visual problems; mood and sleep disorders; cognitive impairment; metabolic acidosis; and decrease in renal function.  As I was looking this up, I noticed that the lead author of this study is the same lead author of the liraglutide study. Phentermine/Topiramate is sold under the brand name Qysmia by Vivus. I had to do some digging to get to the disclosures on this one and what do you know, Dr. Kelly has received grant consideration and consults for Vivus. In fact, with the exception of Megan Oberle, every author of this study either receives funding from/consults for Vivus, or is an employee of Vivus. Megan Oberle lists no conflicts of interest in this 2022 study but, interestingly, in a 2019 study (It is Time to Consider Glucagon-Like Peptide-1 Receptor Agonists for the Treatment of Type 2 Diabetes in Youth) the disclosure states “MO serves as site PI [principal investigator] for study through Vivus Pharmaceuticals” so we know they're not strangers. LisdexamfetamineThis is a stimulant that is approved for kids 6 and older who have ADHD, in those 18 and up for Binge Eating Disorder, and while it is sometimes prescribed off-label for higher-weight kids, the guidelines note that “no evidence available at the time of this review to demonstrate safety or efficacy for the indication of ob*sity in children.”Summing up, there are significant risks of side effects (some life threatending) and not a drug among them has shown anything approaching long-term efficacy. Let's look at the last of the recommendations.RECOMMENDATION: Weight Loss SurgeryThis is the last bit I'll write about today. This section beginsIt is widely accepted that the most severe forms of pediatric ob*sity (ie, class 2 ob*sity; BMI ≥ 35 kg/m2, or 120% of the 95th percentile for age and sex, whichever is lower) represent an “epidemic within an epidemic.”Remember, for a moment, that this phrasing is from authors who swear up and down that they are working to end weight stigma. One wonders what they would have written if they were trying to stigmatize higher-weight children. (Just fyi, if anyone is confused, you can't usefear-mongering language, describing a group of people simply existing in the world at a higher-weight as an “epidemic” without stigmatizing them.)The KAS here (for me the most horrifying of those offered,) isPediatricians and other PHCPs should offer referral for adolescents 13y and older with severe ob*sity (BMI ≥ 120% of the 95th percentile for age and sex) for evaluation for metabolic and bariatric surgery to local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery centers. [I'll note here that at least one of the authors of these guidelines runs just such a facility.]Before we get too far into this, let's be clear about what these surgeries do. They take a child's perfectly functioning digestive system, and put it into a (typically irreversible) disease state forcing, restriction and/or malabsorption (for an explanation of the various surgeries, check out this post.) If this state happens to a child because of disease or accident, it is considered a tragedy. If the child is higher-weight, it is considered, at least by the authors of these guidelines, healthcare.They make the claim “Large contemporary and well-designed prospective observational studies have compared adolescent cohorts undergoing bariatric surgical treatment versus intensive ob*sity treatment or nonsurgical controls. These studies suggest that weight loss surgery is safe and effective for pediatric patients in comprehensive metabolic and bariatric surgery settings that have experience working with youth and their families”To support this, they cite a single study. The study (Laparoscopic Roux-en-Y gastric bypass in adolescents with severe ob*sity (AMOS): a prospective, 5-year, Swedish nationwide study) included 81 subjects who underwent Roux-en-Y gastric bypass.The average weight loss was 36·8 kg over five years, but 11% of those who had the surgery lost less than 10% of their body weight.A full 25%  had to have additional abdominal surgery for complications from the original surgery or rapid weight loss and 72% showed some type of nutritional deficiency. And that's just in five years. Remember that the damage done to the digestive system is permanent. They are recommending this as young as 13, so a five year follow-up only gets these kids to 18. Then what?By the look of their own graph, what comes next may well be more weight gain, since the surgery survivors' weight loss leveled off after year one and started to steadily climb after year two. There's also the impact of those nutrient deficiencies. They also claim that these surgeries lead to a “durable reduction of BMI.” Let's take a look at the studies they cite to prove that.Inge et al., 2018 Comparison of Surgical and Medical Therapy for Type 2 Diabetes in Severely Ob*se AdolescentsThis study lasted two years. It looked at data from 30 adolescents who had weight loss surgery. They averaged 29% weight loss over 2 years and 23% of the subjects had to have a second surgery during those two years.Göthberg et al., 2014, Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid ob*sity--surgical aspects and clinical outcomeThis study just rehashes information from the Olbers study above.O'Brien et al. Laparoscopic adjustable gastric banding in severely ob*se adolescents: a randomized trialThis study is about gastric banding and I'm not sure why they included it because in the paragraph above it they point out that these surgeries are “approved by the FDA only for patients 18 years and older, have declined in use in both adults and youth because of worse long-term effects as well as higher-than expected complication rates” (they cite 18 studies to back up this particular claim.)Olbers et al., 2012 Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe ob*sity: results from a Swedish Nationwide Study (AMOS)These are just the two-year outcomes from the five-year Olbers study aboveOlbers et al. Laparoscopic Roux-en-Y gastric bypass in adolescents with severe ob*sity (AMOS): a prospective, 5-year, Swedish nationwide study.This is the exact same 5-year Olbers study from above, just given a different citation number.Ryder et al., 2018 Factors associated with long-term weight-loss maintenance following bariatric surgery in adolescents with severe ob*sityThis study included 50 subjects who had Roux-en-Y gastric bypass and had a follow-up at year one and another follow-up sometime between years 5 and 12. They were then divided into “regainers” and “maintainers” though by their criteria, “maintainer” subjects could regain, they just couldn't regain more than 20% of the weight they lost prior to their follow-up. Though the study is called “Factors associated with long-term weight-loss maintenance” they were not able to identify any factors that were predictors of “regaining” or “maintaining.” You'll note in the graph below that weight was still trending upward when they stopped following up.So let's recap: They cite 7 studies to back up their recommendation of referrals for these surgeries for kids ages 13 and up. Four of the seven are the same study. One is a study for a surgery that they themselves have said is declining in use, so I'm excluding it. Combined, the rest of the studies followed a grand total of 161 people. The longest follow-up is “5+ years” and the studies consistently showed weight regain that was trending up when follow-up ended, as well as high rates of additional surgery and nutrient deficiencies. This, to me, doesn't come close to justifying a blanket recommendation that every kid 13 and older whose BMI ≥ 120% of the 95th percentile for age and sex be referred for evaluation for weight loss surgery.And when it comes to their criteria for these surgeries, they predicate risk on size. Those with “class 2 ob*sity” are required to have “clinically significant disease” which doesn't make the surgery ethical but, in comparison; children with “class 3 ob*sity” simply have to exist in the world to meet the criteria to have their digestive system put into a permanent disease state. One thing they do point out is that recent data showing multiple micronutrient deficiencies following metabolic and bariatric surgery serve to highlight the need for routine and long-term monitoring. Here we see a serious issue with giving this surgery to adolescents. First of all, they are rarely in control of their access to food. If their parents don't buy them what they need, if a parent loses their job and can no longer afford the supplements they require, if they experience hunger and/or homelessness… there are so many things that could impact a 13-year-old's ability to eat in the very specific ways they need to after the surgery for the rest of their life. Also, these surgeries are going to change the ways that these kids eat - at every school lunch, birthday party, family holiday. Anytime food is served, it is going to become clear that they are different, and if they aren't in charge of preparing the food, there is no guarantee that they will be able to get what they need. And that's if they want to do that. Let's not forget, these are humans who are/will be exploring their independence, including through rebellion, they are humans whose prefrontal cortex is not fully developed, meaning that they can literally lack the ability to fully recognize the consequences of their choices. (Of course, given that we only have five years of follow-up data, I would argue that their doctors and surgical teams also lack the ability to fully recognize the consequences of their choices.)The authors end the section with a fairly shameless plug for insurance coverage of these surgeries. This is another long-time goal of the weight loss industry that has made its way into these guidelines.I think this is a good time for a reminder that thin kids get the same health issues for which higher-weight kids are referred to these surgeries and thin kids are NOT asked to take the risks of these surgeries or to have their digestive systems permanently altered. They just get the ethical, evidence-based treatment for the health issue they actually have. Also, remember that the authors' research methodology specifically excluded research about weight-neutral intervention to see if any health benefits that the surgeries might create could be achieved without the significant (and, from a long-term perspective, largely unknown) risks of these surgeries, and perhaps be more lasting?But there is more to this in terms of informed consent. There are many of the same issues that we see with adults (which I wrote about here). With kids, there is another layer. In the state of California, for example, it is illegal to give a tattoo to someone under the age of 18, even with parental permission. But an eighth grader can make the decision to have their digestive system permanently altered, impacting their life and quality of life in myriad ways, many of which are unknown, and with no prognostics? Given all of this, is informed consent even possible for these kids? I would argue that it is not.Even worse, how many kids' parents, in some combination of weight stigma, concern for their child, and acquiescence to a doctor who may be pressuring them, will make this decision for their child?While I'm sure that there are adolescents who had the surgery and are happy with their outcome, I'm equally sure that there are adolescents who had terrible outcomes and would give anything to not have had the surgery (I know because I hear from them). And I know that the research can't tell us why anyone has the outcome they have. When you combine that with the total lack of long-term follow-up (I'm completely unwilling to consider 5 years “long term” for a lifelong intervention,) I think what we have here are, at best, experimental procedures, not procedures that should receive the kind of blanket recommendations that these guidelines provide for kids as young as 13.Ok, there's a lot more to discuss in these guidelines but I will save that for another newsletter. I hope that the outcry against these guidelines is loud, sustained, and successful in getting them rescinded. Kids deserve far better than this.Finally, I just want to give a quick shout-out to my paid subscribers (I know not everyone can/wants to have a paid subscription and that's totally fine - absolutely no shame at all if you are reading this for free as a subscriber or randomly!) those who are able to pay are allowed me to spend HOURS this week going through these guidelines and creating Thursday's post and this post, I'm just super grateful for the support.I'll be posting additional deep-dives into the research they cite and I'll keep a list here:“New insights about how to make an intervention in children and adolescents with metabolic syndrome” Pérez et al.Did you find this post helpful? You can subscribe for free to get future posts delivered direct to your inbox, or choose a paid subscription to support the newsletter and get special benefits! Click the Subscribe button below for details:Liked this piece? Share this piece:More research and resources:https://haeshealthsheets.com/resources/*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Amidst the battle of the mental health crisis, major depressive disorder stands out as an all-too-common reality for many children and adolescents, but the forces of science and medicine can stand against this foe. Dr. Christopher Drescher, a clinical child psychologist, joins pediatric resident Dr. Daniel Allen and medical student Vuk Lacmanovic to remove the cape from this increasingly common condition and discuss its symptoms, diagnosis, and treatment. Specifically, they will: Define major depressive disorder (MDD) and recognize the common symptoms in both children and adolescents. Formulate a differential diagnosis for patients presenting with depressive symptoms. Recognize validated screening tools for depression in both children and adolescents. Review cognitive behavioral therapy and pharmacotherapy as treatment options. Review appropriate referral to a mental health specialist. Free CME Credit (requires sign-in): https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=12493  References: Bhatia SK, Bhatia SC. Childhood and adolescent depression. Am Fam Physician. 2007 Jan 1;75(1):73-80. PMID: 17225707. Brent DA, Maalouf F. Depressive Disorders (in Childhood and Adolescence). In: Ebert MH, Leckman JF, Petrakis IL. eds. Current Diagnosis & Treatment: Psychiatry, 3e. McGraw-Hill; Accessed November 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2509§ionid=200807606 Clark MS, Jansen KL, Cloy JA. Treatment of childhood and adolescent depression. Am Fam Physician. 2012 Sep 1;86(5):442-8. PMID: 22963063. Fendrich M, Weissman MM, Warner V. Screening for depressive disorder in children and adolescents: validating the Center for Epidemiologic Studies Depression Scale for Children. Am J Epidemiol. 1990 Mar;131(3):538-51. doi: 10.1093/oxfordjournals.aje.a115529. PMID: 2301363. (PDF of CES-DC here) Forman-Hoffman V, McClure E, McKeeman J, Wood CT, Middleton JC, Skinner AC, Perrin EM, Viswanathan M. Screening for Major Depressive Disorder in Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2016 Mar 1;164(5):342-9. doi: 10.7326/M15-2259. Epub 2016 Feb 9. PMID: 26857836. Hathaway EE, Walkup JT, Strawn JR. Antidepressant Treatment Duration in Pediatric Depressive and Anxiety Disorders: How Long is Long Enough? Curr Probl Pediatr Adolesc Health Care. 2018 Feb;48(2):31-39. doi: 10.1016/j.cppeds.2017.12.002. Epub 2018 Jan 12. PMID: 29337001; PMCID: PMC5828899. March JS, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J. The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry. 2007 Oct;64(10):1132-43. doi: 10.1001/archpsyc.64.10.1132. Erratum in: Arch Gen Psychiatry. 2008 Jan;65(1):101. PMID: 17909125. Meister R, Abbas M, Antel J, Peters T, Pan Y, Bingel U, Nestoriuc Y, Hebebrand J. Placebo response rates and potential modifiers in double-blind randomized controlled trials of second and newer generation antidepressants for major depressive disorder in children and adolescents: a systematic review and meta-regression analysis. Eur Child Adolesc Psychiatry. 2020 Mar;29(3):253-273. doi: 10.1007/s00787-018-1244-7. Epub 2018 Dec 8. PMID: 30535589; PMCID: PMC7056684. Rachel A. Zuckerbrot, Amy Cheung, Peter S. Jensen, Ruth E.K. Stein, Danielle Laraque and GLAD-PC STEERING GROUP. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics March 2018, 141 (3) e20174081; DOI: https://doi.org/10.1542/peds.2017-4081 Scott K, Lewis CC, Marti CN. Trajectories of Symptom Change in the Treatment for Adolescents With Depression Study. J Am Acad Child Adolesc Psychiatry. 2019 Mar;58(3):319-328. doi: 10.1016/j.jaac.2018.07.908. Epub 2019 Jan 8. PMID: 30768414; PMCID: PMC6557284. Sharma T, Guski LS, Freund N, Gøtzsche PC. Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. BMJ. 2016 Jan 27;352:i65. doi: 10.1136/bmj.i65. PMID: 26819231; PMCID: PMC4729837. Siu AL; US Preventive Services Task Force. Screening for Depression in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics. 2016 Mar;137(3):e20154467. doi: 10.1542/peds.2015-4467. Epub 2016 Feb 8. PMID: 26908686. Weersing VR, Brent DA, Rozenman MS, Gonzalez A, Jeffreys M, Dickerson JF, Lynch FL, Porta G, Iyengar S. Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care: A Randomized Clinical Trial. JAMA Psychiatry. 2017 Jun 1;74(6):571-578. doi: 10.1001/jamapsychiatry.2017.0429. PMID: 28423145; PMCID: PMC5539834. Weersing VR, Shamseddeen W, Garber J, Hollon SD, Clarke GN, Beardslee WR, Gladstone TR, Lynch FL, Porta G, Iyengar S, Brent DA. Prevention of Depression in At-Risk Adolescents: Predictors and Moderators of Acute Effects. J Am Acad Child Adolesc Psychiatry. 2016 Mar;55(3):219-26. doi: 10.1016/j.jaac.2015.12.015. Epub 2016 Jan 18. PMID: 26903255; PMCID: PMC4783159. Xu Y, Bai SJ, Lan XH, Qin B, Huang T, Xie P. Randomized controlled trials of serotonin-norepinephrine reuptake inhibitor in treating major depressive disorder in children and adolescents: a meta-analysis of efficacy and acceptability. Braz J Med Biol Res. 2016 May 24;49(6):e4806. doi: 10.1590/1414-431X20164806. PMID: 27240293; PMCID: PMC4897997. Zhou X, Cipriani A, Zhang Y, Cuijpers P, Hetrick SE, Weisz JR, Pu J, Giovane CD, Furukawa TA, Barth J, Coghill D, Leucht S, Yang L, Ravindran AV, Xie P. Comparative efficacy and acceptability of antidepressants, psychological interventions, and their combination for depressive disorder in children and adolescents: protocol for a network meta-analysis. BMJ Open. 2017 Aug 11;7(8):e016608. doi: 10.1136/bmjopen-2017-016608. PMID: 28801423; PMCID: PMC5629731. Zhou X, Teng T, Zhang Y, Del Giovane C, Furukawa TA, Weisz JR, Li X, Cuijpers P, Coghill D, Xiang Y, Hetrick SE, Leucht S, Qin M, Barth J, Ravindran AV, Yang L, Curry J, Fan L, Silva SG, Cipriani A, Xie P. Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. Lancet Psychiatry. 2020 Jul;7(7):581-601. doi: 10.1016/S2215-0366(20)30137-1. PMID: 32563306; PMCID: PMC7303954.

What does the body of evidence say on the topic of osteoporosis? Plus: we look at a genuinely breakthrough therapy for metastatic melanoma, and Chris lets you in on a troubling “secret” when it comes to travel health insurance! You will also learn what a “dowager's hump” is and hear Chris sing, and for that we formally apologize.   Block 1: (2:01) Osteoporosis: what it is; bone cells and how they are assessed   Block 2: (9:02) Osteoporosis: bone mineral density, T-score and Z-score; can doctors see signs of osteoporosis in the clinic; causes of osteoporosis; treating it: lifestyle changes, supplements, bisphosphonates, and Prolia; screening guidelines   Block 3: (32:04) Breakthrough therapy for metastatic melanoma: TILs (vs. ipilimumab)   Block 4: (47:53) Travel insurance caveat     * Theme music: “Fall of the Ocean Queen“ by Joseph Hackl. * Assistant researcher: Nicholas Koziris   To contribute to The Body of Evidence, go to our Patreon page at: http://www.patreon.com/thebodyofevidence/.   To make a one-time donation to our show, you can now use PayPal! https://www.paypal.com/donate?hosted_button_id=9QZET78JZWCZE   Patrons get a bonus show on Patreon called “Digressions”! Check it out!     References:   1) Estrogen does reduce the risk of hip fracture from osteoporosis: https://doi.org/10.1001/jama.288.3.321   2) Exercise increases bone mineral density in post-menopausal women: https://doi.org/10.7326/0003-4819-108-6-824 & https://doi.org/10.1001/jama.288.18.2300   3) Calcium and vitamin D supplementation and the risk of fractures: https://doi.org/10.1001/jama.2017.19344   4) Medications can reduce the risk of osteoporotic fractures: https://jamanetwork.com/journals/jama/fullarticle/2685995   5) Screening guidelines from the US Preventive Services Task Force: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening   6) Results from the phase III clinical trial comparing TILs to ipilumumab in advanced melanoma: https://www.nejm.org/doi/full/10.1056/NEJMoa2210233     It's Not Twitter, But It'll Do:   1) Jonathan on the Martial Culture Podcast: https://www.stitcher.com/show/the-martial-culture-podcast/episode/combating-pseudoscience-unscientific-thinkings-in-martial-arts-w-jonathan-jarry-209989826   2) Jonathan's article on the Healy: https://www.mcgill.ca/oss/article/critical-thinking-pseudoscience/healy-old-woo-new-clothes   3) The Hard Fork Podcast: https://www.nytimes.com/2022/10/04/podcasts/hard-fork-technology.html   4) The CTV Montreal News website: https://montreal.ctvnews.ca/video?binId=1.1332485   5) The CBC Player: https://www.cbc.ca/player/news   6) The CJAD website: https://www.iheartradio.ca/cjad   7) Odyssey TV: http://odysseytv.ca/   8) Chris on the CBC, interviewed about mpox: https://www.cbc.ca/news/politics/mpox-outbreak-canada-plateau-1.6696842     Time Machine:   1) Our episode on childbirth: https://bodyofevidence.ca/042-childbirth-and-crowdfunding-quackery   2) Our interview on conspirituality: https://bodyofevidence.ca/interview-matthew-remski-on-conspirituality     Music Credits:   The following music was used for this media project: Music: 3am Glowsticks by Tim Kulig Free download: https://filmmusic.io/song/9166-3am-glowsticks License (CC BY 4.0): https://filmmusic.io/standard-license    

Un nouvel épisode du pharmascope est maintenant disponible! Dans de ce 105ème épisode, à partir de vos savoureuses questions, Nicolas, Sébastien et Isabelle font leur gros possible pour concocter des réponses. Au menu: la testostérone en ménopause, l'obésité et la mortalité, le TDAH et la sélection naturelle, les sirops pour la toux, la caféine et le sommeil, la vitamine D chez l'adulte et la toxicité de la vitamine B12! Les objectifs pour cet épisode sont les suivants: Discuter du concept de confusion résiduelle en obésité Discuter de la littérature évaluant les bénéfices de la vitamine D Comparer les risques et les bénéfices de la prise de DHEA dans le traitement de la ménopause Discuter de l'effet de l'âge sur la sensibilité à la caféine Discuter de la gestion de la vitamine B12 en contexte de dosage suprathérapeutique Discuter des traitements offerts pour traiter la toux sèche et la toux grasse Ressources pertinentes en lien avec l'épisode Eisenberg DT et coll. Dopamine receptor genetic polymorphisms and body composition in undernourished pastoralists: an exploration of nutrition indices among nomadic and recently settled Ariaal men of northern Kenya. BMC Evol Biol. 2008;8:173. Manson JE et coll. Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease. N Engl J Med. 2019;380:33-44. LeBoff MS et coll. Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults. N Engl J Med. 2022;387:299-309. Kahwati LC et coll. Screening for Vitamin D Deficiency in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2021;325:1443-1463. Elraiyah T et coll.. Clinical review: The benefits and harms of systemic dehydroepiandrosterone (DHEA) in postmenopausal women with normal adrenal function: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2014;99:3536-42. Scheffers CS et coll. Dehydroepiandrosterone for women in the peri- or postmenopausal phase. Cochrane Database Syst Rev. 2015;1:CD011066. Frozi J et coll. Distinct sensitivity to caffeine-induced insomnia related to age. J Psychopharmacol. 2018;32:89-95. Clark I, Landolt HP. Coffee, caffeine, and sleep: A systematic review of epidemiological studies and randomized controlled trials. Sleep Med Rev. 2017;31:70-78.

Vitamin C landet im Urin, Vitamin D-Mangel ist ein Rechenfehler — Für allgemein gesunde Erwachsene nicht empfohlen. Moyer VA; US Preventive Services Task Force. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(8):558-564. Schädlich Hohe Dosen Beta-Carotin, Folsäure, Vitamin E oder Selen schädlich: erhöhter Sterblichkeit, Krebs Schlaganfall Rautiainen S, Manson JE, Lichtenstein AH, Sesso HD. Dietary supplements and disease prevention: a global overview. Nat Rev Endocrinol. 2016;12(7):407-420. Besser aus gesunder, ausgewogener Ernährung NEM kein Ersatz für gesunde ausgewogene Ernährung. Mikronährstoffe in Lebensmitteln in der Regel besser aufgenommen plus weniger potenzielle Nebenwirkungen Rautiainen S, Manson JE, Lichtenstein AH, Sesso HD. Dietary supplements and disease prevention: a global overview. Nat Rev Endocrinol. 2016;12(7):407-420 Marra MV, Boyar AP. Position of the American Dietetic Association: nutrient supplementation. J Am Diet Assoc. 2009;109(12):2073-2085. Vitamin B12 Indiziert Perniziösen Anämie (Blutarmut), intramuskulär Verminderte Aufnahme (IF), Gastritis (Magenschleimhautentzündung), vermindertes Angebot (Alkoholismus) Langzeitanwendung von AM wie Protonenpumpenhemmer und Metformin https://www.deutsche-apotheker-zeitung.de/daz-az/2010/daz-24-2010/vitamin-b12-spiegel-sinkt-unter-metformin Vitamin D Kein Vitamin Pro-Hormon, Cholecalciferol, über UVB-Licht und Wärme in der Haut aus einer Vorstufe gebildet in Leber und Niere in aktive Form Calcitriol = Steroidhormon (wie Cortison). Supplementation keine Vitamin-, sondern Hormontherapie. Mangel-Irrtum oder Desinformation? Gemessen anhand Serum 25-hydroxyvitamin D [25(OH)D] in ng/ml: >30 ng/ml OK 29-20 ng/ml, Unterversorgung 70 J: 16 ng/ml RDA Höchstbedarf: 1-70 J: 16 ng/ml >70 J: 20 ng/ml Beide Werte gehen von minimal bis keiner Sonnenexposition aus Weit verbreitetes Missverständnis: Höhere RDA/Empfohlene Tägliche Aufnahme = „Grenzwert“ Gesamte Bevölkerung >20 ng/ml für gute Knochengesundheit Realität Mehrheit (etwa 97,5%) braucht

At the end of September, the US Preventive Services Task Force made the recommendation that all adults under the age of 65 years be screened for anxiety by their healthcare provider. Why is this newsworthy? It includes screening all adults including those who do not have a diagnosed mental health disorder and are not showing any signs or symptoms of anxiety.  This same recommendation was made for kids ages 8-18 earlier in April.  In this episode, we're diving into why these recommendations were made, access to treatment, and our thoughts on if this will have an impact when it comes to helping friends and family with anxiety issues.  Show Notes:  References mentioned include: Screening for Depression, Anxiety, and Suicide Risk in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force   Thank you for listening to The Happy Eating Podcast. Tune in weekly on Thursdays for new episodes! For even more Happy Eating, head to our website!  https://www.happyeatingpodcast.com Learn More About Our Hosts:  Carolyn Williams PhD, RD: Instagram: https://www.instagram.com/realfoodreallife_rd/ Website: https://www.carolynwilliamsrd.com Facebook: https://www.facebook.com/RealFoodRealLifeRD/ Brierley Horton, MS, RD Instagram: https://www.instagram.com/brierleyhorton/ Got a question or comment for the pod? Please shoot us a message!  happyeating@gmail.com Produced by Lester Nuby OE Productions 

At the end of September, the US Preventive Services Task Force made the recommendation that all adults under the age of 65 years be screened for anxiety by their healthcare provider. Why is this newsworthy? It includes screening all adults including those who do not have a diagnosed mental health disorder and are not showing any signs or symptoms of anxiety.  This same recommendation was made for kids ages 8-18 earlier in April.  In this episode, we're diving into why these recommendations were made, access to treatment, and our thoughts on if this will have an impact when it comes to helping friends and family with anxiety issues.  Show Notes:  References mentioned include: Screening for Depression, Anxiety, and Suicide Risk in Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force   Thank you for listening to The Happy Eating Podcast. Tune in weekly on Thursdays for new episodes! For even more Happy Eating, head to our website!  https://www.happyeatingpodcast.com Learn More About Our Hosts:  Carolyn Williams PhD, RD: Instagram: https://www.instagram.com/realfoodreallife_rd/ Website: https://www.carolynwilliamsrd.com Facebook: https://www.facebook.com/RealFoodRealLifeRD/ Brierley Horton, MS, RD Instagram: https://www.instagram.com/brierleyhorton/ Got a question or comment for the pod? Please shoot us a message!  happyeating@gmail.com Produced by Lester Nuby OE Productions 

The United States Preventative Services Task Force issued new recommendations for the use of vitamins, minerals, and multivitamins for the prevention of cardiovascular disease and cancer. This is a revision from the 2014 recommendations and is based on recent data. Host Geoff Wall will provide a review of the recommendations – and evidence on these over-the-counter products. The GameChanger Based on the new USPSTF recommendations, most vitamins and supplements have insufficient data to determine their benefits versus harm. However, the USPSTF recommends against the use of beta carotene or vitamin E supplementation for the prevention of cancer or cardiovascular disease.  Show Segments 00:00 – Introductions 01:15 – Vitamins, Minerals, and Supplements Regulations and Controversies 06:11 – USPSTF Recommendations 10:07 – Beta Carotene in Cancer and Cardiovascular Disease 11:49 – Vitamin A Supplementation 12:14 – Vitamin E Supplementation 12:52 – Multivitamin Use 15:16 – Vitamin D & Calcium Supplementation  17:40 – Folic Acid Supplementation  18:50 – Vitamin C Supplementation  19:05 – The GameChanger 22:58 – Connecting to Practice 23:40 – Closing Remarks  Host Geoff Wall, PharmD, BCPS, FCCP, CGP Professor of Pharmacy Practice, Drake University Internal Medicine/Critical Care, UnityPoint Health References and resources:US Preventive Services Task Force. Vitamin, Mineral, and Multivitamin Supplementation to Prevent Cardiovascular Disease and Cancer: US Preventive Services Task Force Recommendation Statement.Redeem your CPE or CME creditCPE (Pharmacist)CME (Physician)Get a membership & earn CE for GameChangers Podcast episodes (30 mins/episode) Pharmacists: Get a Membership Prescribers: Get a Membership   Continuing Education Information:Learning Objectives:1. Discuss the use of vitamin E for cardiovascular disease prevention2. Describe the USPSTF recommendations for vitamins, minerals, and multivitamins0.05 CEU | 0.5 HrsACPE UAN: 0107-0000-22-281-H01-PInitial release date: 08/08/22Expiration date: 08/08/2023Additional CPE & CME details can be found here

Dental's pharmacology expert, Tom Viola, RPh, returns to the show to share some interesting words recently published in the Journal of the American Medical Association about beta carotene and vitamin E and what the US Preventive Services Task Force is saying about them. This is a must-listen for dental professionals not only for themselves but their patients as well.

Czemu służą nużeńce żyjące na naszych twarzach i jak się zmieniają na przestrzeni pokoleń? Czy nowe terapie oparte na bakteriach jelitowych mogą pomóc w leczeniu depresji? Czym jest pęseta akustyczna i do czego może służyć? Czy uda się wprowadzić powszechne, proste, tanie i szybkie badanie równowagi u osób starszych i właściwie po co to robić? Jak skuteczne i czy w ogóle są tak powszechne suplementy diety w zapobieganiu nowotworom i chorobom serca? O tym wszystkim opowiem w tym odcinku podkastu Naukowo :)Jeśli uznasz, że warto wspierać ten projekt to zapraszam do serwisu Patronite, każda dobrowolna wpłata od słuchaczy pozwoli mi na rozwój i doskonalenie tego podkastu, bardzo dziękuję za każde wsparcie!Zapraszam również na Facebooka, Twittera i Instagrama, każdy lajk i udostępnienie pomoże w szerszym dotarciu do słuchaczy, a to jest teraz moim głównym celem :) Na stronie Naukowo.net znajdziesz więcej interesujących artykułów naukowych, zachęcam również do dyskusji na tematy naukowe, dzieleniu się wiedzą i nowościami z naukowego świata na naszym serwerze Discord - https://discord.gg/mqsjM5THXrŹródła użyte przy tworzeniu odcinka:O'Connor EA, Evans CV, Ivlev I, Rushkin MC, Thomas RG, Martin A, Lin JS. Vitamin and Mineral Supplements for the Primary Prevention of Cardiovascular Disease and Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022 Jun 21;327(23):2334-2347. doi: https://doi.org/10.1001/jama.2021.15650. PMID: 35727272.US Preventive Services Task Force, Mangione CM, Barry MJ, Nicholson WK, Cabana M, Chelmow D, Coker TR, Davis EM, Donahue KE, Doubeni CA, Jaén CR, Kubik M, Li L, Ogedegbe G, Pbert L, Ruiz JM, Stevermer J, Wong JB. Vitamin, Mineral, and Multivitamin Supplementation to Prevent Cardiovascular Disease and Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Jun 21;327(23):2326-2333. doi: https://doi.org/10.1001/jama.2022.8970. PMID: 35727271.Elana Spivack, "Beer might actually improve gut health study finds", https://www.inverse.com/mind-body/beer-improves-gut-health-studyY. Zeng et al., "Manipulation and Mechanical Deformation of Leukemia Cells by High-Frequency Ultrasound Single Beam," in IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, vol. 69, no. 6, pp. 1889-1897, June 2022, doi: https://doi.org/10.1109/TUFFC.2022.3170074.Sophia Chen, "Forget Lasers. The Hot New Tool for Physicists Is Sound", https://www.wired.co.uk/article/acoustic-sound-waves-engineers-physicsAraujo CG, de Souza e Silva CG, Laukkanen JA, et alSuccessful 10-second one-legged stance performance predicts survival in middle-aged and older individualsBritish Journal of Sports Medicine Published Online First: 21 June 2022. doi: http://doi.org/10.1136/bjsports-2021-105360Najwyższa Izba Kontroli, https://www.nik.gov.pl/aktualnosci/system-opieki-geriatrycznej.htmlRoss Pomeroy, "10-second balance test is a powerful predictor of death for older adults", https://bigthink.com/health/balance-predicts-death-older-adults/Schaub, AC., Schneider, E., Vazquez-Castellanos, J.F. et al. Clinical, gut microbial and neural effects of a probiotic add-on therapy in depressed patients: a randomized controlled trial. Transl Psychiatry 12, 227 (2022). https://doi.org/10.1038/s41398-022-01977-zGilbert Smith,...

Hvordan gikk Hong Kong fra å håndtere pandemien godt i begynnelsen til å ha verdens høyeste covid-19-dødsrater nå? Hvordan vil USA se ut etter Roe Vs Wade, der abort vil være forbudt i mange stater? Hvor effektivt er skatt på sukkerholdige drikker? Det er en viss assosiasjon mellom kaffeinntak og redusert dødelighet – blir dette «nullet ut» hvis man har sukker eller kunstig søtningsmidler i kaffen man drikker? Hvem bør screenes for prediabetes? Hvordan går det med de overlevende ofrene etter masseskytinger i USA? Som et tiltak mot masseskytinger foreslår mange republikanere opptrapping av bevæpnet politi – eller bevæpnede lærere – på skolene. Men vil det hjelpe? Hva er den globale sykdomsbyrden av RS-virus? Hvordan står det til med forekomsten av HPV-infeksjoner etter innføringen av vaksiner? Hvordan går det med pasienter som blir operert på dagtid av kirurger som har hatt vakt hele natten? Sjefredaktør Are Brean tar deg gjennom siste nytt fra internasjonale medisinske tidsskrifter.Tilbakemeldinger kan sendes til stetoskopet@tidsskriftet.no. Stetoskopet produseres av Caroline Ulvin Johansson, Are Brean og Julie Didriksen ved Tidsskrift for Den norske legeforening. Ansvarlig redaktør er Are Brean. Jingle og lydteknikk: Håkon Braaten / Moderne media Coverillustrasjon: Stephen Lee Artikler nevnt:How Hong Kong's vaccination missteps led to the world's highest covid-19 death rate Navigating Loss of Abortion Services — A Large Academic Medical Center Prepares for the Overturn of Roe v. Wade Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis Evaluating the Evidence on Beverage Taxes: Implications for Public Health and Health Equity Association of Sugar-Sweetened, Artificially Sweetened, and Unsweetened Coffee Consumption With All-Cause and Cause-Specific Mortality: A Large Prospective Cohort StudyPrediabetes and Diabetes Screening Eligibility and Detection in US Adults After Changes to US Preventive Services Task Force and American Diabetes Association RecommendationsInjury Characteristics, Outcomes, and Health Care Services Use Associated With Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019 Presence of Armed School Officials and Fatal and Nonfatal Gunshot Injuries During Mass School Shootings, United States, 1980-2019 Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in children younger than 5 years in 2019: a systematic analysis Human Papillomavirus Vaccine Impact and Effectiveness Through 12 Years After Vaccine Introduction in the United States, 2003 to 2018 Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before

O retorno do bolus com Joanne e Marcela falando sobre AAS na profilaxia primária para doença cardiovascular (DCV)! Elas abordam 3 tópicos: - História de AAS na prevenção de DCV - Recomendação atual e os principais estudos que motivaram a mudança de recomendação (ASPREE, ARRIVE E ASCEND) - O que fazer com quem já usa? Tá imperdível! Referências: 1. Aimo A, De Caterina R. Aspirin for primary prevention of cardiovascular disease: Advice for a decisional strategy based on risk stratification. Anatol J Cardiol. 2020;23(2):70-78. 2. Berger JS. Aspirin for Primary Prevention—Time to Rethink Our Approach. JAMA Netw Open.2022;5(4):e2210144. 3. Bowman L, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med 2018; 379:1529-1539 4. Chiang KF, Shah SJ, Stafford RS. A Practical Approach to Low-Dose Aspirin for Primary Prevention. JAMA. 2019;322(4):301-302 5. Gaziano JM, et al. Aspirin to Reduce Risk of Initial Vascular Events - ARRIVE. Lancet 2018; 392: 1036–46 6. McNeil JJ, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018; 379:1519-1528 7. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, Póvoa RMS, et al. Atualização da Diretriz de Prevenção Cardiovascular da Sociedade Brasileira de Cardiologia – 2019. Arq. Bras. Cardiol. 2019;113(4):787-891 8. Raber I, et al. The rise and fall of aspirin in the primary prevention of cardiovascular disease. Lancet 2019; 393: 2155–67 9. US Preventive Services Task Force. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA.2022;327(16):1577–1584.

Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, is also former Administrator of the Centers for Medicare & Medicaid Services. A pediatrician by background, Dr. Berwick has served on the faculty of the Harvard Medical School and Harvard School of Public Health, and on the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. He has also served as Vice Chair of the US Preventive Services Task Force, the first "Independent Member" of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality. He served two terms on the Institute of Medicine's (IOM's) Governing Council, was a member of the IOM's Global Health Board, and served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. Recognized as a leading authority on health care quality and improvement, Dr. Berwick has received numerous awards for his contributions. In 2005, he was appointed "Honorary Knight Commander of the British Empire" by Her Majesty, Queen Elizabeth II in recognition of his work with the British National Health Service. Dr. Berwick is the author or co-author of over 160 scientific articles and six books. He currently serves as Lecturer in the Department of Health Care Policy at Harvard Medical School. Follow Don on Twitter Nana Twum-Danso, MD, MPH, FACPM, ​Senior Vice President, Global, Institute for Healthcare Improvement (IHI), leads all global strategy and client development, with top-line revenue responsibility. Previously she was Managing Director for Health at The Rockefeller Foundation, overseeing a strategy designed to transform the practice of public health through data science. She is a public health and preventive medicine physician with 20 years of experience in health policy, practice, strategy, monitoring, learning, evaluation, research, and philanthropy at local, national, and international levels. Dr. Twum-Danso is also an Adjunct Assistant Professor in the Department of Maternal and Child Health at the Gillings School of Global Public Health at the University of North Carolina, Chapel Hill. She worked at the Task Force for Global Health in Atlanta, Georgia; was Director of IHI's nationwide CQI initiative in Ghana; Senior Program Officer in the MNCH Department at the Bill & Melinda Gates Foundation; independent consultant; and Founder and CEO of MAZA, a social enterprise that provided on-demand health care transportation for pregnant women and sick infants in remote areas of Ghana. She also served on technical advisory committees for the World Health Organization, the US National Academy of Sciences, Engineering and Medicine, and the Canadian International Development Research Centre. Dr. Twum-Danso received her undergraduate and medical education from Harvard University and her public health and preventive medicine residency training from Emory University.  Follow Nana on Twitter.

In this limited series of episodes, we have conversations with a variety of experts and community leaders in the field of maternal and child health to discuss how to advance maternal health equity. In this episode we spoke with CHET Director/Founder -- Dr. Melissa Simon. Melissa A. Simon, MD, MPH is the George H. Gardner Professor of Clinical Gynecology, Vice Chair of Research in the Department of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine. She is also the Founder and Director of the Center for Health Equity Transformation and the Chicago Cancer Health Equity Collaborative. She serves as the Robert H. Lurie Comprehensive Cancer Center's Associate Director for Community Outreach and Engagement. She is an expert in implementation science, women's health across the lifespan, minority health, community engagement and health equity. She has been recognized with numerous awards for her substantial contribution to excellence in health equity scholarship, women's health and mentorship, including her recent election to the National Academy of Medicine and the Association of American Physicians. She has received the Presidential Award in Excellence in Science Mathematics and Engineering Mentorship and is a Presidential Leadership Scholar. She is a former member of the US Preventive Services Task Force and serves on the NIH Office of Research in Women's Health Advisory Committee. For more information on maternal health projects, please visit: - https://www.feinberg.northwestern.edu/sites/chet/ - https://well-mama.org/

Melissa A. Simon, MD, MPH, discusses unmet needs regarding clinical trials for underserved populations with cancer, highlights the key objectives of the ECOG-ACRIN Health Equity Committee and the US Preventive Services Task Force, and shares her advice to health care professionals in the cancer space who are working to bridge some of these disparities.

Between the latest online fads and the crazy media headlines, it's easier more than ever to get confused about your health. If you want to make better decisions about your health so you can feel better and live longer, you've come to the right place.   There are so many questions about Vitamin D today especially in the media regarding its relevance to general health, thyroid health and how it is related to COVID. There are a lot of arguments as to how Vitamin D can be beneficial to humans, and the recent one is its contribution to fight COVID-19. I stumbled across one of Dr. Deva Boone's articles about people easily getting hypercalcemia or high calcium levels even from mild excesses of Vitamin D. I recommended before to avoid higher levels of Vitamin D as it is less useful and makes you less productive but it turns out it can also be quite dangerous.    Joining us is Dr. Deva Boone to understand more of how Vitamin D works in our body and what are the best practices to think about for our general welfare.   Dr. Deva Boone is one of the most experienced parathyroid surgeons and has become a renowned expert on calcium and Vitamin D. She attended Cornell University medical school, completed a general surgery residency in New York City, and an endocrine surgery fellowship in Chicago. She spent the past six years as a parathyroid surgeon at the Norman Parathyroid Center, and was the Medical Director there for the past three years. She is currently obtaining an executive MBA at the University of South Florida, and is planning to open a parathyroid surgery center in Arizona in 2021. Key Takeaways:   [0:35] Introduction to Dr. Deva Boone [2:02] Dr. Boone shares a story about Shannon with a medical mystery. [2:35] Shannon showing symptoms related to Catatonia - a psychiatric disorder. [3:27] Suspected parathyroid disease because of consistent high calcium levels. [4:10] Sharing symptoms with parathyroid disease and psychiatric disorder. [4:45] Dr. Boone examined deeper and shifted to high levels of vitamin D. [5:00] Results of taking vitamin D as a medication for a long period.  [5:40] High levels of vitamin D cause high calcium levels. [6:00] Putting a stop on taking vitamin D as a cure. [6:45] Diagnosing patients with high calcium levels because of vitamin D [7:25] Effects of having high calcium levels. [7:50] Dr. Boone explains vitamin D is a steroid hormone. [9:20] High calcium blood levels that cause toxic range of vitamin D. [11:30] Problems in measuring vitamin D. [13:01] Vitamin D in milk to avoid bone deformities. [13:30] Other health effects of low or high in vitamin D [14:28] Range of vitamin D levels and the health effects according to race. [15:43] Correlation is not causation - associating low vitamin D to a lot of diseases. [17:38] Ignoring high calcium levels and its impact. [18:35] The body keeps a tight range of calcium levels. [19:00] General effects of high calcium levels. [19:50] Hich calcium level is a parathyroid tumor until proven otherwise. [21:01] Normal range of calcium levels according to age. [22:13] Parathyroid surgery as the best cure of parathyroid disease. [24:25]  Considering surgery rather than just maintaining lifestyle medicine. [25:50] How Parathyroid surgery works? [26:55] Vitamin D is not definitive but plays a role in our immune system and could help prevent COVID. [29:40] Taking vitamin D more than the normal range is not recommended. [31:00] Vitamin D taken as a medication instead of a supplement. [31:35] Safe and average number of taking different supplements containing vitamin D. [33:58] Closing statement with Dr. Deva Boone. [34:35] Is there a topic you'd like to hear?   For more details about Dr. Deva Boone, visit her website www.devaboone.com or connect with her through these platforms:   Facebook: https://www.facebook.com/deva.boone  LinkedIn: https://www.linkedin.com/in/deva-boone-md-mba-95a31983/  Twitter: @DevaBoone Topic references:  https://parathyroidpeeps.com/2019/04/17/confused-about-vitamin-d-supplementation-in-relation-to-parathyroid-disease-expert-parathyroid-surgeon-dr-boone-explains/    https://www.parathyroidqanda.com/question/low-vitamin-d-but-normal-calcium-levels   https://www.inspire.com/groups/parathyroid/discussion/ask-the-expert-parathyroid-expert-and-surgeon-dr-deva-boone-aug-3-7/   https://www.southwestparathyroid.com/about   https://www.healthgrades.com/physician/dr-deva-boone-ggyws    You can check out her articles and learn more about Vitamin D: Vitamin D, part 1: https://www.devaboone.com/post/vitamin-d-part-1-back-to-basics Vitamin D, part 2: https://www.devaboone.com/post/vitamin-d-part-2-shannon-s-story Vitamin D, part 3: https://www.devaboone.com/post/vitamin-d-part-3-the-evidence  Vitamin D and Covid: https://www.devaboone.com/post/vitamin-d-and-covid Physiology of Vitamin D Resources:   Christakos S, Dhawan P, Verstuyf A, Verlinden L, Carmeliet G. “Vitamin D: Metabolism, Molecular Mechanism of Action, and Pleiotropic Effects”. Physiol Rev. 2016;96(1):365-408. https://doi.org/10.1152/physrev.00014.2015 Bikle DD. “Vitamin D metabolism, mechanism of action, and clinical applications.” Chem Biol. 2014;21(3):319-329. https://doi.org/10.1016/j.chembiol.2013.12.016   Randomized controlled trials of Vitamin D Resources:   VITAL trial Manson JE, Cook NR, Lee IM, et al. “Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease.” N Engl J Med. 2019;380(1):33-44.  ViDA (Vitamin D Assessment) Trial Scragg  R, Stewart  AW, Waayer  D,  et al.  “Effect of monthly high-dose vitamin D supplementation on cardiovascular disease in the vitamin D assessment study : a randomized clinical trial”.  JAMA Cardiol. 2017;2(6):608-616.  RECORD trial follow-up study Avenell A, MacLennan GS, Jenkinson DJ, et al. “Long-Term Follow-Up for Mortality and Cancer in a Randomized Placebo-Controlled Trial of Vitamin D3 and/or Calcium” (RECORD Trial), J Clin Endo & Met, Volume 97, Issue 2, 1 February 2012, Pages 614–622.   RECORD Trial Grant AM, Avenell A, Campbell MK, et al. “Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people” (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet. 2005;365(9471):1621-1628.  VITAL-BONE Trial LeBoff MS, Chou SH, Murata EM, et al. “Effects of Supplemental Vitamin D on Bone Health Outcomes in Women and Men in the VITamin D and OmegA-3 TriaL (VITAL)”. J Bone Miner Res. 2020;35(5):883-893. D2d Trial Pittas AG, Dawson-Hughes B, Sheehan P, et al. Vitamin D Supplementation and Prevention of Type 2 Diabetes. N Engl J Med. 2019;381(6):520-530.  VIOLET (Vitamin D to Improve Outcomes by Leveraging Early Treatment) trialNational Heart, Lung, and Blood Institute PETAL Clinical Trials Network, Ginde AA, Brower RG, et al. “Early High-Dose Vitamin D3 for Critically Ill, Vitamin D-Deficient Patients”. N Engl J Med. 2019;381(26):2529-2540. List of significant meta-analyses on Vitamin D:   Zhang Y, Fang F, Tang J, et al. “Association between vitamin D supplementation and mortality: systematic review and meta-analysis”. BMJ. 2019;366:l4673. Bjelakovic G, Gluud LL, Nikolova D, et al. “Vitamin D supplementation for prevention of mortality in adults”. Cochrane Database Syst Rev. 2014;(1):CD007470.  Bjelakovic  G, Gluud  LL, Nikolova  D, et al. “Vitamin D supplementation for prevention of cancer in adults”. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD007469. Chung M, Lee J, Terasawa T, Lau J, Trikalinos TA. “Vitamin D with or without calcium supplementation for prevention of cancer and fractures: an updated meta-analysis for the US Preventive Services Task Force”. Ann Intern Med. 2011;155(12):827-838.   Avenell A, Mak JC, O'Connell D. “Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men”. Cochrane Database Syst Rev. 2014;4:CD000227. Jolliffe DA, Greenberg L, Hooper RL, et al. “Vitamin D supplementation to prevent asthma exacerbations: a systematic review and meta-analysis of individual participant data” [published correction appears in Lancet Respir Med. 2018 Jun;6(6):e27]. Lancet Respir Med. 2017;5(11):881-890. Martineau AR, Jolliffe DA, Greenberg L, et al. “Vitamin D supplementation to prevent acute respiratory infections: individual participant data meta-analysis”. Health Technol Assess. 2019;23(2):1-44.   What did you learn about today's topic? Let us know by leaving a review! Visit these links to learn more: https://www.drchristianson.com/ Dr. Christianson on Facebook| (http://www.facebook.com/DrAlanChristianson/ Dr. Christianson on Instagram (http://www.instagram.com/dralanchristianson/)   Subscribe for more Medical Myths, Legends, & Fairytales: Apple Podcasts (https://podcasts.apple.com/us/podcast/medical-myths-legends-fairytales/id1467232418) Spotify (https://open.spotify.com/show/0HaZ75TpOCazsRQSG0AOFs) YouTube (https://www.youtube.com/user/Alannmd/videos)  

Best Buy makes another move into healthcare with plans to buy Current Health. The US Preventive Services Task Force is narrowing guidance on who should take aspirin to prevent heart disease. And nurses say patients are increasingly hostile and violent.

The US Preventive Services Task Force has drafted a statement reversing the recommendation that those 60 and over take daily aspirin to prevent heart attack or stroke. Raiders head coach, Jon Gruden, has resigned following reports of emails that were homophobic, racist and misogynistic. Listeners comment.  See omnystudio.com/listener for privacy information.

The US Preventive Services Task Force has drafted a statement reversing the recommendation that those 60 and over take daily aspirin to prevent heart attack or stroke. Raiders head coach, Jon Gruden, has resigned following reports of emails that were homophobic, racist and misogynistic. Listeners comment.  See omnystudio.com/listener for privacy information.

The US Preventive Services Task Force is considering making several changes to its guidance on taking a daily aspirin to prevent heart disease and stroke. On Tuesday, the task force posted a draft statement recommending that adults ages 40 to 59 who are at a higher risk for cardiovascular disease -- but do not have a history of the disease -- decide with their clinician whether to start taking aspirin, based on their individual circumstances. This is the first time the task force has recommended that adults in their 40s talk to their doctors about whether to take aspirin for heart health. The draft also says that adults 60 and older should not start taking aspirin to prevent heart disease and stroke because new evidence shows that potential harms cancel out the benefits, according to the task force.To learn more about how CNN protects listener privacy, visit cnn.com/privacy

Hoje, no Check-up Semanal, nosso programa de podcast que traz as principais atualizações da última semana, o editor-chefe médico do Portal PEBMED, Ronaldo Gismondi, comenta: os guidelines atualizados da Surviving Sepsis Campaign; recomendações da US Preventive Services Task Force para uso de aspirina para prevenir pré-eclâmpsia; e um estudo que avaliou o melhor momento de iniciar a anticoagulação pós-AVC em paciente com fibirlação atrial.

- Quem deve fazer? - Até quando? - Como fazer? - O que fazer quando o resultado vem alterado? Rapha, Joanne e Iago respondem essas e outras perguntas! E ainda dão um bônus sobre as síndromes familiares, Polipose Adenomatosa Familiar (PAF) e Síndrome de Lynch Referências: 1- Screening for colorectal cancer: Strategies in patients at average risk. Uptodate Agosto 2021. Author:Chyke Doubeni, MD, FRCS, MPHSection Editors:Joann G Elmore, MD, MPHJ Thomas Lamont, MDDeputy Editor:Jane Givens, MD 2- USPSTF Recommendation: Screening for Colorectal Cancer. Entrevista do Jama, disponível em https://edhub.ama-assn.org/jn-learning/audio-player/18612046 3- DAVIDSON, Karina W. et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA, v. 325, n. 19, p. 1965-1977, 2021. 4- NEE, Judy; CHIPPENDALE, Ryan Z.; FEUERSTEIN, Joseph D. Screening for colon cancer in older adults: risks, benefits, and when to stop. In: Mayo Clinic Proceedings. Elsevier, 2020. p. 184-196. 5- http://cancerscreening.eprognosis.org/ 6- Shaukat et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021, The American Journal of Gastroenterology, vol. 116, n. 3 - p. 458-479, March 2021. 7- SYNGAL, Sapna et al. ACG clinical guideline: genetic testing and management of hereditary gastrointestinal cancer syndromes. The American journal of gastroenterology, v. 110, n. 2, p. 223, 2015. 8- Daniel C Chung, Linda H Rodgers. Familial adenomatous polyposis: Screening andmanagement of patients and families; Acesso em uptodate.com em setembro/2021 9- Michael J Hall. Lynch syndrome (hereditary nonpolyposis colorectalcancer): Cancer screening and management. Acesso em uptodate.com em setembro/2021 10- Finlay A Macrae. Overview of colon polyps; Acesso em uptodate.com em setembro/2021

Are federal regulators convinced that a COVID-19 booster is necessary? Find out about this and more in today's PV Roundup podcast..

The United States Preventative Services Task Force (USPSTF) announced new recommendations for diabetes screening. Approximately 34.5% of the US population has pre-diabetes – frequently attributed to the 75% of US adults with an overweight or obese body mass index. What makes 35 years old the new test screening age for diabetes compared to 40? Redeem your CPE or CME credit here! References and resources: US Preventive Services Task Force. Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(8):736–743. doi:10.1001/jama.2021.12531Continuing Education Information:Learning Objectives: 1. Identify individuals who should be screened for diabetes2. Describe the role of racial and ethnic disparities in diabetes0.05 CEU | 0.5 HrsACPE UAN: 0107-0000-21-323-H01-PInitial release date: 9/07/21Expiration date: 9/07/22Complete CPE & CME details can be found here

Davidson KW et al. Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA 2021 Aug 24; 326:736. (https://doi.org/10.1001/jama.2021.12531)  The Task Force found moderate-certainty evidence that screening is beneficial for nonpregnant adults (age range, 35–70) who are overweight (i.e., body-mass index [BMI], ≥25 kg/m2) or obese (BMI, ≥30 kg/m2) and have no symptoms of diabetes. Referring patients for, or directly providing, effective preventive interventions is recommended (B recommendation).  The main change from the 2015 recommendation is the lower age threshold for screening — 35 rather than 40. The decision was made because of the increasingly younger age of onset for diabetes and the known benefits of intervention at a wide range of ages. Notably, the USPSTF found little direct evidence that screening improves clinical outcomes;   Lifestyle modifications and metformin are considered appropriate interventions for preventing or delaying onset of diabetes; however, metformin is not approved for this specific use by the U.S. FDA. ---- NO NO NO NO NO NO NO you cant do that..    Aringer M et al. European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) SLE classification criteria item performance. Ann Rheum Dis 2021 Feb 10; 80:775. (https://doi.org/10.1136/annrheumdis-2020-219373) Diagnosising SLE—its always lupus till its not lupus but new diagnosis criteria In 2019, the European League Against Rheumatism and the American College of Rheumatology published the following classification criteria for systemic lupus erythematosus (SLE; Ann Rheum Dis 2019; 78:1151):·                     Positive antinuclear antibody (ANA) test with titer ≥1:80 is a required “entry criterion.”·                     If the ANA criterion is met, points are assigned from seven clinical categories and three immunologic test categories; a criterion is not counted if another cause is more likely than SLE.  A score ≥10 is considered to be consistent with SLE. When these criteria were validated, sensitivity for SLE was 96%, and specificity was 93%. But ANA what about ANA Sensitivity and specificity of ANA were 99.5% and 19.4%, respectively. NEXT  Gómez-Outes A et al. Meta-analysis of reversal agents for severe bleeding associated with direct oral anticoagulants. J Am Coll Cardiol 2021 Jun 22; 77:2987. (https://doi.org/10.1016/j.jacc.2021.04.061)Use of direct oral anticoagulants (DOACs) is associated with about a 3% annual risk for major bleeding, though that varies by age, comorbidity profile, and concomitant therapies.  investigators examined clinical outcomes associated with the use of 4-factor prothrombin complex concentrate (4PCC), idarucizumab, or andexanet for severe DOAC-associated bleeding.These drugs are greatBut if you do bleed then about 20% of the time we cant get hemostasis with mortality around 18% DESPITE getting reversal agents.. This is good to talk to your patients about— The risk of bleeding in 1 and 33 per year..Out of every 3300 people treated about 20 people will have a bleed that isn't controlled and 18 of those people will die.It sounds like a lot but remember without these drugs the risk of stroke is much much higher, of course depending on your comorbid conditions. NEXT  Cardiovascular risk prediction in type 2 diabetes before and after widespread screening: a derivation and validation study - ClinicalKeyLancet, The, 2021-06-12, Volume 397, Issue 10291, Pages 2264-2274, Copyright © 2021 Elsevier Ltd Formulas for cardiovascular (CV) risk calculations are based on population studies and generally include diabetes as a major risk factor. Do formulas that were derived when diabetes usually was diagnosed at later stages overestimate CV risk for people in whom diabetes is diagnosed early?? Basically long ago we diagnosed in DM at a1c of 12 not we diagnosis it at a1c of 6-6.5-7—even prediabetes at a1c of 5.5……Those are not the same population so now are we over diagnosing CV risk??? The answer for this new zeeland study was yes--In this modern diabetic population, the median 5-year risk for an adverse CV event, as estimated by the new formula, was 4.0% in women and 7.1% in men. The older formula overestimated median risk in women (14.7%) and in men (17.1%).This is has to do with new Zealand not the the more recent and commonly used American pooled cohort equation but even that I would love to see put through the ringer as many of the studies were done back in the 90s, over thirty years ago, when we were quite as sharp about diagnosing diabetes yet…either way you have to remember the ascvd risk score is for discussion it is not evidence based gold it is a conversation starter   Next DVT – I am always confused when people say airline travel is a risk factor. I have sat on my couch for 6 hours without moving and I never got a dvt so why would being on a plane for 3 hours. Well maybe it is something I don't understand about air travel because as this paper Munger JA et al. Television viewing, physical activity and venous thromboembolism risk: The REasons for Geographic and Racial Differences in Stroke (REGARDS) study. J Thromb Haemost 2021 Jun 2; [e-pub]. They looked to see if tv watching was associated with DVT and it was not – it didn't matter if you just watched a little bit of tv per day or over 4 hours of tv per day, there was no association with increase DVT and TV hours per day once accounting for total activity.. yes those that are watching TV move less and are more obese but is it he TV watching or just all the risk factors…. This article says it is the risk factors. Last articleKelly CR et al. Prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol 2021 Jun; 116:1124. (https://doi.org/10.14309/ajg.0000000000001278)    Oral vancomycin or fidaxomicin generally is favored for treating patients with nonsevere CDI, but metronidazole is acceptable for low-risk patients — especially when cost is a factor. Patients with severe CDI should be treated with either oral vancomycin or fidaxomicin (but not metronidazole). Severe disease is defined as having a leukocytosis >15,000 white blood cells/mm3 or a creatinine level of >1.5 mg/dL. Fecal microbiota transplantation (FMT) should be considered for refractory or severe CDI. *******A first recurrence should be treated with tapering/pulsed-dose vancomycin or fidaxomicin if it was not the initial therapy. ********A patient experiencing a second or further recurrence of CDI should be treated with FMT, delivered via a colonoscope or capsules, with enemas used when colonoscopy or capsules are not available. Repeat FMT can be used to treat a recurrence within 8 weeks of initial FMT. *****Patients with recurrent CDI who are not FMT candidates or have relapsed after FMT can be given long-term oral vancomycin prophylaxis to prevent recurrences. Oral vancomycin prophylaxis also can be considered when patients with recurrent CDI are given systemic antibiotics.

Many people have elevated blood pressure when they visit their doctor’s office, so if you’ve been told your blood pressure is high that needs to be confirmed before you are put on any medicines to lower it. That’s according to new guidelines from the US Preventive Services Task Force. Greg Prokopowicz, a blood pressure expert […]

João, Kaue e Rapha com a participação do psiquiatra Rodolfo discutem sobre rastreio, impacto e tratamentos do transtorno associado ao uso do álcool. Minutagem em breve. 1. Kriston L, Hölzel L,Weiser A-K, Berner MM, Härter M. Meta-analysis: are 3 questions enough to detect unhealthy alcohol use? Ann Intern Med. 2008;149(12):879-888. doi:10.7326 2. Weisner C, Matzger H, Kaskutas LA. How important is treatment? one-year outcomes of treated and untreated alcohol-dependent individuals. Addiction. 2003;98(7):901-911. doi:10 .1046/j.1360-0443.2003.00438.x 3. Barata IA, Shandro JR, Montgomery M, et al. Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review. West J Emerg Med. 2017;18(6):1143-1152. doi:10.5811/westjem.2017.7.34373 4. Falk D,Wang XQ, Liu L, et al. Percentage of subjects with no heavy drinking days: evaluation as an efficacy endpoint for alcohol clinical trials. Alcohol Clin Exp Res. 2010;34(12):2022-2034. doi:10.1111/j.1530-0277.2010.01290.x 5. Anton RF, O’Malley SS, Ciraulo DA, et al; COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17): 2003-2017. doi:10.1001/jama.295.17.2003 WEERAKOON, Sitara M.; JETELINA, Katelyn K.; KNELL, Gregory. Longer time spent at home during COVID-19 pandemic is associated with binge drinking among US adults. The American Journal of Drug and Alcohol Abuse, 2020. POLLARD, Michael S.; TUCKER, Joan S.; GREEN, Harold D. Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA network open, v. 3, n. 9, p. e2022942-e2022942, 2020 BASTOS, Francisco Inácio Pinkusfeld Monteiro et al. III levantamento nacional sobre o uso de drogas pela população brasileira. 2017. O’Connor EA, Perdue LA, Senger CA, et al. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 171. AHRQ Publication No. 18-05242-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2018. 3 NATIONAL INSTITUTE ON ALCOHOL ABUSE; ALCOHOLISM (US). Helping Patients who Drink Too Much: A Clinician's Guide: Updated 2005 Edition. US Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 2007. 2 CURRY, Susan J. et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. Jama, v. 320, n. 18, p. 1899-1909, 2018. MILLSTEIN, Susan G.; MARCELL, Arik V. Screening and counseling for adolescent alcohol use among primary care physicians in the United States. Pediatrics, v. 111, n. 1, p. 114-122, 2003. Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment [published online June 20, 2016]. Pediatrics. doi:10.1542/peds.2016-1211 PEREIRA, Bruna Antunes de Aguiar Ximenes; SCHRAM, Patricia Franco Cintra; AZEVEDO, Renata Cruz Soares de. Avaliação da versão brasileira da escala CRAFFT/CESARE para uso de drogas por adolescentes. Ciência & Saúde Coletiva, v. 21, p. 91-99, 2016. MÉNDEZ, Eduardo Brod et al. Uma versão brasileira do AUDIT-Alcohol Use Disorders Identification Test. Pelotas: Universidade Federal de Pelotas, p. 69, 1999. Richard Saitz, Murray B Stein, Michael Friedman. Psychosocial treatment of alcohol use disorder. Uptodate Abril 2021. Approach to treating alcohol use disorder. Richard Saitz, Andrew J Saxon, Michael Friedman. Uptodate Abril 2021. [26/5 20:26] Raphael Coelho Cm Epm: KELLY, John F.; HUMPHREYS, Keith; FERRI, Marica. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews, n. 3, 2020. [26/5 20:26] Raphael Coelho Cm Epm: Brief intervention for unhealthy alcohol and oth

The US Preventive Services Task Force on Tuesday lowered the recommended age to start screening for colon and rectal cancers from 50 to 45. The task force, which is the leading panel for medical guidance in the US, released a draft of the recommendation in October. The final recommendation statement, published Tuesday in the journal JAMA, says all adults ages 45 to 75 years should be screened for colorectal cancer. This recommendation is for asymptomatic people of average risk, with no prior diagnosis of colorectal cancer, history of colon or rectal polyps or personal or family history of genetic disorders that put them at higher risk. The task force also recommended selective screening among adults ages 76 to 85 years based on a patient's overall health, prior screening history and preferences.To learn more about how CNN protects listener privacy, visit cnn.com/privacy

Lung cancer is the leading cause of death from cancer, but if it’s found at an earlier stage, when it is small and before it has spread, it is more likely to be successfully treated. To take us through the state of lung cancer screening in the US—big picture issues, challenges faced by patients and clinicians, and reasons for excitement—we were joined by two leading experts in the field. Christopher Slatore, MD, MS, is an investigator for the Portland VA Health Service Research and Development Center of Innovation, Center to Improve Veteran Involvement in Care (CIVIC). He’s Associate Professor of Medicine at Oregon Health & Science University, and he’s a pulmonologist who conducts lung cancer screening. He’s also an American Cancer Society Research Scholar Grant recipient. Anne Melzer, MD, MS, is Assistant Professor of Medicine at the University of Minnesota Medical School. She is an Investigator at the Minneapolis VA Center for Care Delivery and Outcomes Research. And she is a pulmonologist who is the medical director of the lung cancer screening at the Minneapolis VA. The American Cancer Society recommends annual lung cancer screening with a low-dose CT scan for certain people at higher risk for lung cancer. Visit cancer.org for details: https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html 4:18 – Welcome Dr. Melzer and Dr. Slatore 5:51 – Dr. Melzer on the lung cancer burden in the United States 8:46 – Dr. Slatore on the state of lung cancer screening in the US 12:08 – Some of the big picture problems they’re trying to solve related to lung cancer screening 16:47 – The US Preventive Services Task Force’s recent recommendation regarding lung cancer screening: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening 23:01 – Challenges that exist for patients when it comes to lung cancer screening 25:28 – Some of the frustrations clinicians have with lung cancer screening 30:39 – “We need to make it easier for patients and primary care providers to do lung cancer screening.” 34:57 – It all comes down to an old Seinfeld episode: https://www.youtube.com/watch?v=4T2GmGSNvaM 36:31 – The impact of ACS funding on Dr. Slatore’s research 37:28 – The aspect of her research that Dr. Melzer is most excited about 38:50 – Messages they’d like to share with cancer patients, survivors, and caregivers

Jaime Perales, PhD, presents statistics, screening tools and useful resources for primary care providers for Alzheimer’s disease. The KIDs list is presented. Question of the month: Fever and Cough.Introduction: KIDs List and Cognitive Impairment in the ElderlyBy Hector Arreaza, MDToday is May 3, 2021.  In family medicine, we believe in caring for patients “from the cradle to the grave.” During this introduction, we want to inform first of the KIDs list[1] and then some updates on cognitive impairment screening in older adults[2].First, KIDs stand for Key Potentially Inappropriate Drugs in Pediatrics. It is a list of medications that are potentially inappropriate in children. It contains 67 drugs with their risks, recommendations, strength of recommendation and quality of evidence. Common meds include anti-infectives, antipsychotics, dopamine antagonists and GI agents. 85% of these meds require a prescription, and are taken by mouth, or used by parenteral route or even for external use. For example: Mineral oil, oral, carries the risk of lipid pneumonitis, recommended to avoid in patients younger than 1 year old, this recommendation is strong with low quality of evidence. For all the “abuelas” (Spanish for grandmothers) out there, listen to this: Camphor carries a risk of seizures, the recommendation is “use with caution in children.” However, the recommendation is weak and quality of evidence is low, but the concern is enough to include it on the list, in other words, use “vi-vah-pore-oo” with caution in children. I recommend you look up the KIDs list and use your clinical judgment to incorporate it into your practice. From childhood, now we go to the elderly. On February 25, 2020, the USPSTF posted their final recommendation statement regarding screening for cognitive impairment in older adults. This is a Grade I recommendation (Insufficient Evidence). It means that more research is needed to recommend for or against it. This is the same recommendation given in 2014. An article published in JAMA on the same date, Feb 25, 2020, reports that screening instruments can adequately detect cognitive impairment, however there is no evidence that this screening improves patient or caregiver outcomes or causes harm. It is still uncertain if early detection of cognitive impairment is important to provide interventions for patients or caregivers with significant clinical benefits.Jaime Perales, PhD, will present some statistics on Alzheimer’s disease, he will explain some useful tools to screen for cognitive impairment and address the issue of Alzheimer’s disease at the primary care level. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.  Question of the Month: Fever and CoughWritten by Hector Arreaza, MD, read by Claudia Carranza, MD, and Valerie Civelli, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. He has no surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition? Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!____________________________Screening for Alzheimer’s. With Jaime Perales Puchalt, PhD, and Hector Arreaza, MD Jaime Perales Puchalt is an Assistant Professor in the Department of Neurology. His main areas of interest include dementia among minorities and populations of Latin American origin in the Americas. He currently spearheads the Latino Alzheimer's education efforts at the University of Kansas Alzheimer’s Disease Center (KU ADC) and the Latino Cohort in which he recruits and conducts clinical dementia assessments of English and Spanish speaking Latinos. He has also led the integration of the Spanish National Alzheimer's Coordinating Center Unified Data Set 3.0 into REDCap. Together with Dr. Vidoni, Dr. Perales developed Envejecimiento Digno, a curriculum to increase Alzheimer's disease awareness among individual Latino community with different literacy levels.  Dr. Perales completed his MS in Psychology at the University of València, and his MPH in Public Health and PhD in Biomedicine at the University Pompeu Fabra, Barcelona. He started his research career at the University of València, where he collaborated in several stress-related projects among breast cancer patients, Latin American immigrants and caregivers of schizophrenia patients. Dr. Perales co-managed a four-year European Commission-funded multi-country study on healthy aging (COURAGE in Europe) at the Parc Sanitari Sant Joan de Déu. He also spent one year as a visiting researcher at the Institute of Public Health, University of Cambridge conducting dementia-related epidemiological research and collaborating in successful aging literature reviews. At Juntos: Center for Advancing Latino Health (KU), he contributed to the cultural and linguistic adaptation of several smoking cessation interventions for Latinos[3].Questions discussed during this episode:  Incidence and prevalence of dementia in the US: under-diagnosis, death risk, caregiver, Recommendations on screening for dementia by national organizations: American Academy of Neurology, examining models of dementia care (page 22), USPSTF, grade I, no evidence, screening early improves outcomes; ARDADBest evidence-based tools for screening for dementia: MMSE, MoCA (better for MCI), AD8, MiniCog. Useful resources for primary care providers: Alzheimer’s Association: Unidos Podemos (soap opera), NIH Caring for a person with Alzheimer’s Disease, Course: USDHHS,  Any other information you would like to provide us: The course, Jul 23, 2021, and Sep 3, 2021. Conclusion.Now we conclude our episode number 50 “Screening for Alzheimer’s Disease”. You heard from our experts the importance of assessing and treating your patients with Alzheimer’s Disease. We hope you can find all the resources mentioned during our interview with Jaime Perales, make sure you check our episode notes to find the links or just Google them, they are readily available online. Do not forget to send us your answer to the question of the month: What are your top 3 differential diagnosis and acute management of a 69-year-old male with new onset of fever, cough, shortness of breath, and right lower lobe consolidation. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ariana Lundquist, Jaime Perales, Claudia Carranza, and Valerie Civelli. Audio edition: Suraj Amrutia. See you next week! References and resources mentioned during this episode:Meyers RS, Hellinga RC, Hoff DS. The KIDs List: Medications That Are Potentially Inappropriate in Children. Am Fam Physician. 2021 Mar 15;103(6):330. PMID: 33719376. https://www.aafp.org/afp/2021/0315/p330.html Cognitive Impairment in Older Adults: Screening, February 25, 2020. U.S. Preventive Services Task Force.  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening Patnode CD, Perdue LA, Rossom RC, et al. Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2020;323(8):764–785. doi:10.1001/jama.2019.22258.  https://jamanetwork.com/journals/jama/article-abstract/2761650 KU Medical Center, The Univeristy of Kansas, Core Faculty, https://www.kumc.edu/ku-adc/core-faculty/jaime-perales-puchalt-phd.html 2021 Alzheimer’s Disease Facts and Figures, Special Report on Race, Ethnicity and Alzheimer's in America, published by the Alzheimer’s Association, Chicago, Illinois, USA.  https://www.alz.org/media/documents/alzheimers-facts-and-figures.pdf Examining Models of Dementia Care: Final Report, U.S. Department of Health & Human Services, September 1, 2016, https://aspe.hhs.gov/pdf-report/examining-models-dementia-care-final-report ¡Unidos Podemos! (Fotonovela, Spanish), Alzheimer’s Association, http://www.alz.org/espanol/downloads/Novella_spanish_081213.pdf Together We Can! (Picture Novel, English), Alzheimer’s Association, http://www.alz.org/espanol/downloads/Novella_english_081213.pdf Alzheimer’s Disease, Caring for a Person with Alzheimer's Disease: Your Easy-to-Use Guide, U.S. Department of Health & Human Services, National Institute on Aging, https://order.nia.nih.gov/sites/default/files/2019-03/Caring_for_a_person_with_AD_508_0.pdf 

Episode 47: Hearing Carotid Lung.  Dr Civelli explains the updates on screening for lung cancer, hearing loss and carotid artery stenosis; Kafiya explains the use of bupropion and naltrexone in methamphetamine abuse, question of the month pneumonia.Introduction: Methamphetamine useBy Kafiya Arte, MS4, and Ariana Lundquist, MD.Today is April 12, 2021.Bakersfield, California, has a methamphetamine (meth) epidemic currently ravaging this area. We as health care workers believe we can spot somebody addicted to meth from a mile away by their characteristic “older-than-stated-age” appearance and obvious “meth mouth”. However, the actual scope of the epidemic is much larger. It’s not just people who are experiencing homelessness that are addicted to, and dying from, meth.  I saw while volunteering at a needle exchange at Weill Park, people getting out of nice-looking cars wearing clean, pressed clothes with sharps containers full of used needles ready to exchange. One man even had a teacup poodle in tow. It’s clear that meth can affect anybody.  Between May 10 and June 10, 2014, 31.8% of randomly selected patients in the ED of Kern Medical admitted to having used methamphetamine at least once in their life. It’s not just the individual who addicted to meth who is affected. 36.1% of children removed from their home by child protective services in Kern County during the month of May 2014 were cases that involved methamphetamine[1]. Meth accounted for nearly 75% of all drugs seized by the Bakersfield Police Department[2]. Statewide, meth kills more Californians than any single opioid alone[3]. Amphetamine overdose deaths have increased 212% from 777 in 2012 to 2,427 in 2018 in California. In 2020, Kern County had more than double the rate of deaths related to overdose of psychostimulants, of which meth was the dominant drug, compared to the state of California (20.48/100k residents versus 8.21/100k residents, respectively)[3]. This devastating problem, unfortunately, does not have a currently FDA-approved drug to treat it. A promising study called Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. Bupropion decreases the dysphoria of meth withdrawal that drives continued use; while naltrexone decreases cravings, therefore preventing relapse, as it does with alcohol use disorder.  A total of 403 participants with nearly daily meth use were included in the two-stage randomized, double blind trial conducted at 8 different sites from May 23, 2017 to July 25, 2019. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo.  The results of the study showed a 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. A response was defined as at least three meth negative urine samples out of four samples obtained at the end of each of the two stages.  The trial concluded that although the response rate among participants that received naltrexone and bupropion was low, it was higher than that among participants who received placebo. Although the ADAPT-2 trial did not provide any recommendations that can be adapted to clinical practice, it serves as a starting point for further research of the additive or synergistic effects of bupropion and naltrexone in the treatment of meth use disorder.  Hopefully, it will also serve as a catalyst for more pioneering research regarding the legitimization of meth use disorder as a treatable disease with major medical, psychiatric, socioeconomic and legal consequences. Clinicians should stay up to date with research regarding meth use disorder such as ADAPT-2, as it is our duty to understand the health crises that affect our patients on a daily basis, and the tools we can use to treat them.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ________________________________Question of the MonthWritten by Hector Arreaza, MD, read by Jennifer Thoene, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!     Hearing Carotid LungBy Valerie Civelli, MD, and Ariana Lundquist, MDScreening for hearing loss in older adultsHearing loss definition: To answer this, let’s first talk Hertz and Decibels. Many studies and guidelines define mild hearing loss as the inability to hear frequencies associated with speech processing under 25 dB and moderate hearing loss as the inability to hear those frequencies under 40 dB[5].  The most important range for speech processing is typically 500 to 4000 Hz. To check hearing, we often use pure-tone audiometry, which is the most standard quantitative measurement; however, this is not a perfect test. There is often discordance between objectively measured deficits and subjective perceptions of hearing problems. In one study, 1 in 5 persons who reported hearing loss had a normal hearing test result, while 6% of those with severe hearing loss detected on audiometry did not report feeling that they had hearing loss.[6]  I wonder if their significant other would agree with the 6% who self-reported no hearing loss but failed the hearing test?  That would be a great study! Risk factors for hearing loss: The #1 risk factor for hearing loss is increasing age. Hearing loss increases with age after 50 attributable to normal degeneration of hair cells in the ear.  This leads to the most common cause of hearing loss in older adults: Presbycusis.  Presbycusis is your diagnosis for patients with gradual, worsening of perceived high-frequency tones. Insufficient evidence for screening: If the patient reports hearing loss, you should order a hearing test. However, on March 23, 2021, for asymptomatic adults 50 years or older, the US Preventive Services Task Force (USPSTF) published a statement that re-confirmed the 2012 recommendations. That is, current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults without symptoms. This statement aligns with the AAFP and is referenced in their practice guidelines. This recommendation applies to asymptomatic older adults (age >50 years) who have not noticed any issues with their hearing. It excludes adults with conductive hearing loss, congenital hearing loss, sudden hearing loss, or hearing loss caused by recent noise exposure, or those reporting signs and symptoms of hearing loss.Screening for Carotid Artery StenosisDo not screen: For the general adult population without symptoms of carotid artery stenosis, do not screen. This is a Grade D recommendation for all adults without a history of stroke or neurologic signs or symptoms of a transient ischemic attack. This is a re-endorsement statement made in Feb of this year, 2021, recommitting to 2014 statements.  The evidence continues to show that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. The USPSTF has made other recommendations related to stroke prevention and cardiovascular health. These include: Screening for high blood pressure in adultsScreening for abdominal aortic aneurysmInterventions for tobacco smoking cessation in adults, including pregnant personsInterventions to promote a healthy diet and physical activity for the prevention of cardiovascular disease:In adults with cardiovascular risk factorsIn adults without known cardiovascular risk factorsAspirin use to prevent cardiovascular disease and colorectal cancerStatin use for the primary prevention of cardiovascular disease in adultsLung Cancer Screening Grade B recommendation: On March 9, 2021, there are updated Grade B recommendations by the USPSTF.  For patients 50-80 years old, with a 20 pack-year history of smoking and still smoke or quit within 15 years, annual screening with low dose CT is now recommended.Stop screening when a person has not smoked for 15 year, or has a condition that substantially limits life expectancy or limits their ability to undergo curative lung surgeryThe USPSTF modified guidelines so we are screening earlier and with lower pack years.  It used to be recommended to do low dose Chest CT at age 55-80, but it’s now at 50-80.  Also, pack-years was 30 but it’s now at 20 pack-years that we should screen for lung cancer.  So, screen sooner at 50, and at lower threshold of 20. Screen for lung cancer in male and female patients.Conclusion: Now we conclude our episode number 47 “Hearing Carotid Lung”. Dr Civelli gave us an update on USPSTF screening in asymptomatic adults. For hearing loss, there is insufficient evidence to give a recommendation. For carotid artery stenosis, there is a grade D, meaning do not screen. And for lung cancer screening, it is a grade B recommendations, meaning screen your patients. Don’t forget to order a low dose CT of chest in patients of ANY sex, OLDER than 50 years, WITH a 20 pack/year smoking history, and currently smoking or quit less than 15 years ago. That’s a mouthful, but once you start following the guideline, it gets easier to recall.Remember, even without trying, every night you go to bed being a little wiser. Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Jennifer Thoene, Valerie Civelli, Kafiya Arte, Arianna Lundquist, Jacqueline Uy, and voluntarily unidentified medical assistants. Audio edition: Suraj Amrutia. See you next week! _____________________References:The Impact of Methamphetamine in Kern County: 2014, Update September 2014, Kern County Mental Health Department, https://transforminglocalcommunities.com/wp-content/uploads/2018/05/tlc-the-impact-of-meth-in-kern-county-2014-update.pdf Klein, Kerry, To Bakersfield Cops, Concern For Opioids Grows - But Meth Is Still King. Valley Public Radio News, NPR for Central California. May 1, 2019, https://www.kvpr.org/post/bakersfield-cops-concern-opioids-grows-meth-still-king#stream/0 California Opioid Overdose Surveillance Dashboard, California Department of Public Heallh, https://skylab.cdph.ca.gov/ODdash/, accessed on March 27, 2021. Klein, Kerry, Meth Is Making A Comeback In California – And It’s Hitting The San Joaquin Valley Hard. Valley Public Radio News, NPR for Central California. June 28, 2019, https://www.kvpr.org/post/meth-making-comeback-california-and-it-s-hitting-san-joaquin-valley-hard#stream/0 Feltner C, Wallace IF, Kistler CE, et al. Screening for Hearing Loss in Older Adults: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Mar. (Evidence Synthesis, No. 200.) Chapter 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK569275/   US Preventive Services Task Force. Screening for Hearing Loss in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(12):1196–1201. doi:10.1001/jama.2021.2566. https://jamanetwork.com/journals/jama/fullarticle/2777723.    Screening for Hearing Loss in Older Adults, March 23, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening#fullrecommendationstart Screening for Asymptomatic Carotid Artery Stenosis, February 02, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening. Lung Cancer: Screening, March 09, 2021, US Preventive Services Task Force, https://uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening.    

Childhood obesity is a prevalent problem but perhaps not as commonly addressed in doctors’ appointments due to a variety of reasons. Dr. Dusty Marie Narducci, MD speaks with Dr. Caitlyn Mooney, MD on the AMSSM Sports Medcast all about childhood obesity. In part one of their conversation, Dr. Narducci tackles the following questions: · Why is it important to know about childhood obesity? · What defines obesity, and what causes it in children? · What are BMI z-scores, and how much can clinicians rely on BMI as a measurement? · What are the comorbidities of obesity in childhood and adolescents? · What are the musculoskeletal implications of obesity? · What is the prognosis of childhood obesity? Related Articles and Links: BMI Z-Score and Percentile Calculator: https://www.bcm.edu/bodycomplab/BMIapp/BMI-calculator-kids.html BMI Percentile Calculator for Child and Teen https://www.cdc.gov/healthyweight/bmi/calculator.html Boutelle KN, Rhee KE, Liang J, et al. Effect of Attendance of the Child on Body Weight, Energy Intake, and Physical Activity in Childhood Obesity Treatment: A Randomized Clinical Trial. JAMA Pediatr 2017; 171:622. US Preventive Services Task Force, Grossman DC, Bibbins-Domingo K, et al. Screening for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA 2017; 317:2417. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics 2011; 128 Suppl 5:S213

In this podcast, Talia Segal and Michael Waxman, MD, MPH, talk about their research that investigated the demographics of patients with hepatitis C virus (HCV) before and after the US Preventive Services Task Force updated its screening guidelines. More at www.consultant360.com

FDA 批准HER2酪氨酸激酶抑制剂用于治疗HER2阳性的乳腺癌Lancet 低剂量阿司匹林可以预防初产妇早产？JAMA 男性补充叶酸和锌对精液质量和胎儿活产有影响吗？妥卡替尼（tucatinib）人表皮生长因子受体2 （HER2）阳性的、转移性乳腺癌患者在使用多种HER2靶向药物治疗后，若病情仍出现进展，则治疗选择便很有限。妥卡替尼（tucatinib）是一种口服的、HER2酪氨酸激酶的、高选择性抑制剂。2020年4月，妥卡替尼（tucatinib）被FDA批准用于治疗HER2阳性乳腺癌。《HER2CLIMB研究：妥卡替尼、曲妥珠单抗、卡培他滨治疗HER2阳性转移性乳腺癌的3期临床研究》New England Journal of Medicine，2020年2月 (1)研究纳入HER2阳性的、复发性、转移性乳腺癌患者共480人，在曲妥珠单抗和卡培他滨的联合治疗的基础上，随机联用妥卡替尼或安慰剂。联用妥卡替尼组和安慰剂组中，1年无进展生存率分别为33.1%和12.3%（疾病进展或死亡的风险比为0.54，P

FDA 批准HER2酪氨酸激酶抑制剂用于治疗HER2阳性的乳腺癌Lancet 低剂量阿司匹林可以预防初产妇早产？JAMA 男性补充叶酸和锌对精液质量和胎儿活产有影响吗？妥卡替尼（tucatinib）人表皮生长因子受体2 （HER2）阳性的、转移性乳腺癌患者在使用多种HER2靶向药物治疗后，若病情仍出现进展，则治疗选择便很有限。妥卡替尼（tucatinib）是一种口服的、HER2酪氨酸激酶的、高选择性抑制剂。2020年4月，妥卡替尼（tucatinib）被FDA批准用于治疗HER2阳性乳腺癌。《HER2CLIMB研究：妥卡替尼、曲妥珠单抗、卡培他滨治疗HER2阳性转移性乳腺癌的3期临床研究》New England Journal of Medicine，2020年2月 (1)研究纳入HER2阳性的、复发性、转移性乳腺癌患者共480人，在曲妥珠单抗和卡培他滨的联合治疗的基础上，随机联用妥卡替尼或安慰剂。联用妥卡替尼组和安慰剂组中，1年无进展生存率分别为33.1%和12.3%（疾病进展或死亡的风险比为0.54，P

Jeanny Aragon-Ching, MD, FACP, a medical oncologist and clinical program director of genitourinary (GU) cancers at the Inova Schar Cancer Institute, shares her concerns over the decline in the screening, diagnosis, and treatment of prostate and other GU cancers amid the COVID-19 pandemic, and highlights promising clinical trials underway to advance the fields of prostate, bladder, and kidney cancers. Transcript ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. Joining me today is Dr. Jeanny Aragon-Ching, a medical oncologist who serves as the clinical program director of Genitourinary Cancers at the Inova Schar Cancer Institute in Virginia. She joins me to discuss the worrying decline in screenings for prostate cancer due to the COVID-19 pandemic. Dr. Aragon-Ching also highlights clinical trials underway to advance the treatment of prostate, bladder, and kidney cancers. Dr. Aragon-Ching reports no conflicts of interest relating to the issues discussed in this podcast. And full disclosure relating to old episodes of the Daily News podcast are available on our transcripts at ASCO.org/podcasts. Dr. Aragon-Ching, it's great to have you on the podcast today. Dr. Jeanny Aragon-Ching: Thank you so much, Geraldine, for having me here. ASCO Daily News: Well, screening for prostate cancer is vitally important. What are your concerns about the long-term impact of delayed screenings, diagnosis, and treatment in this setting? Dr. Jeanny Aragon-Ching: Yes. So generally there have been already reports actually of observed decline in the common screening and diagnostic procedures and practices reflecting the impact of the COVID-19 pandemic on cancer prevention and early detection, signaling possible downstream effects on the timing and staging of future cancer diagnosis. Now, the issue is there has been no major guidelines or guidance regarding recommendations for screening during the pandemic. Now, one closely aligned guidance, if you will, from the NCCN, actually it's more for management, it suggests that patients with known low risk or certainly very low-risk prostate cancer may actually defer staging active surveillance or even testing for treatment until conditions are deemed safe. Therefore, determination of who really needs to be absolutely screened and certainly diagnosed, I think, is key. So especially since the subject of screening in prostate cancer has always actually been controversial even while the U.S. Preventive Services Task Force set forth the D recommendation, which is recommendation against PSA screening except for those target ages, let's say, between 55 and 69 years of age, they had a C recommendation, which involves individualized decision-making. And that means for us, we always have to have that dialogue with the patients in order to weigh the pros and cons of screening, especially during these times. So therefore, I mean, there's really no current standards that are set forth. A lot of it I think would be tailored to each individualized person and patient as well as physicians in practice during these times of pandemic. ASCO Daily News: Right. Well, COVID-19 will continue to be a threat for some time. So, how is the oncology care community to fill the gap in diagnostic services? Should cancer screenings, biopsies, and surgeries press on? If you see a patient that really needs treatment now, you, I assume, will proceed, correct? Dr. Jeanny Aragon-Ching: Correct. Yeah. Now, I do think the gaps in diagnostic services is really actually being remedied by performing other alternative services, if you will. So, for instance, remote telehealth services have gotten and gained ground since the COVID-19pandemic. And my general recommendation is, and the thinking really is minimal harm is really expected with delays in care certainly for certain types of risk of prostate cancer, or even bladder cancer or kidney cancers. If one were to delay the treatment for, let's say, 3 months, especially when we weigh the risk of mortality or morbidity from being exposed to COVID-19, I think those are the critical issues. Now, I would say that diagnosis and treatment for patients with GU cancers really require prioritization, adjustments for, let's say, screening biopsies, as well as individualized tailored approach to the diagnosis and treatment. The oncologic community, the GU community as a whole I think quickly filled that gap, as I mentioned earlier, by restricting non-urgent, in-person clinic visits, as well as adopting more remote telehealth visits to continue care that the physicians provide. So in terms of prioritization of the goals, patients, let's say, who need to undergo immediate diagnostic procedures and biopsies to make a diagnosis would be a priority. So especially for those who are deemed to have high-risk disease, for those who are likely to have high-grade disease, let's say, muscle-invasive bladder cancer, or let's say, big tumors that are seen on abdominal imaging for a renal cell cancer because we don't typically biopsy, let's say, renal masses to diagnose renal cell carcinoma. And as a general rule of thumb, procedures and treatments that are curative in intent would be considered high priority, whereas benefits of care from treatments certainly has to be weighed against a potential risk for infections and morbidity from COVID-19. Identifying the risks are important as well. So, for instance, treatment may be safely deferred for patients with low risk or certainly even intermediate-risk patients, whereas surgery may be delayed in most high-risk patients or alternative treatments, let's say, a neoadjuvant hormone therapy, coupled with external beam radiation, may be a treatment of choice with regard to the pandemic, and then may be a feasible alternative. So there's a lot of changes that are being set forth. Now with regard to radiation, there's also some concern, for instance, for lymphopenia, for those who undergo radiation. So actually identifying the patients who really would benefit from upfront treatment is key. So for patients with bladder cancer, let's say, who have muscle-invasive bladder cancer, they undergo surgery. We call it TURBT. And they undergo intravesical treatment. So a lot of it highly depends on the goal of the therapy. Is it curative in intent? Certainly if they undergo neoadjuvant chemotherapy, that adds to the layer of complexity for these patients because they are now being exposed to chemotherapy. But on the other hand, it is an important treatment with the goal of curative intent. And there's also something to be said about the varying institutional procedures. For instance, each institution has in place their own safeguards to screen, let's say, or treat patients with COVID-19. So in our institution, for instance, doing rapid COVID-19 tests to assess prior to performing these procedures, anesthesia or procedures that are high-risk for aerosolizing like respiratory secretions, would be of paramount importance. So I think there's a lot of institutional guidance also that comes into play in this day and age of COVID-19 in the treatment of our patients who have a diagnosis of GU cancers. ASCO Daily News: Absolutely. What can you tell us about new developments in diagnostics in the prostate cancer space which have truly advanced the field, resulting in fewer unnecessary biopsies and hopefully making men a little less reluctant to actually take care of their prostate health? Dr. Jeanny Aragon-Ching: Yes, that's a great question. And emerging data suggests that targeting using a combined MRI and an ultrasound fusion approach may perhaps increase the detection of significant high-risk prostate cancer, which, after all, is really the clinically significant and meaningful cancers that we need to treat, and therefore lead to perhaps lower detection of the lower risk prostate cancer that may not need to be treated. Now, it's important to recognize also that a negative MRI does not necessarily exclude the possibility of cancer. And therefore, biomarkers have been in place to be also helpful to perhaps avoid a biopsy in someone, let's say, who has a negative result. Now, there are numerous tests or biomarkers out there available. I always have said that a lot of times it is dealer's choice. It's highly dependent on what physicians are comfortable using, [and] what the availability is within their own institutions. And what the payers or insurance would pay for or cover. But there are several promising ones out there that help further predict if a patient has a high-risk of having a diagnosis of clinically significant prostate cancer. So, for instance, there was a urine base marker, it's called IntelliScore, so it looks at three different genes that would be able to discriminate a higher grade group of cancer versus a lower grade group. And that would help physicians and providers to help further define who needs to be biopsied, especially in this day and age, again, of COVID-19, so that they would be able to predict the likelihood of higher risk prostate cancer that ultimately needs to be treated. And that's not the only one out there that's currently available. There's other things like blood work or blood tests, like 4Kscore, which combines different parameters like free PSA, total PSA, intact PSA, that will help further predict high-grade prostate cancer. And the bottom line is all of these tests would help the physicians, the urologist hopefully to decide who they need to biopsy and prioritize versus those who can safely wait based on just an elevated PSA alone. ASCO Daily News: Well, African American men are at a significantly greater risk of getting prostate cancer. Can you talk about the health disparities that exist in this setting? And do you think the field is doing enough to address this? Dr. Jeanny Aragon-Ching: Mm-hmm. Yeah, so prostate cancer disparities actually constitutes one of the most complex issues in cancer today. So it is known that African American men unfortunately do have disproportionately higher incidence of prostate cancer, easily about 60% to 70% higher compared to Caucasian men counterparts. And they also have a higher 2-fold increased risk of prostate cancer death. So these are very relevant in the practice of prostate cancer in the field. African American men are also more likely to be diagnosed at a younger age. They tend to have more advanced and aggressive disease. And African genetic ancestry is really unfortunately not a modifiable risk factor, so when we talk about genetics...so there are potential reasons why this is so, why African American men may have a higher incidence or mortality. One potential explanation could be genetics. So it has been found that several genetic variants may be a little bit more common in African-American men. So, for instance, like 8q24 mutation in a tumor suppressor gene, there's differences in microRNA regulation, and they tend to, unfortunately, present with more aggressive tumors. And certain gene mutations also can lead to poor outcomes, let's say, P53 mutations, CDK M18, which is more commonly seen in African American men. Now, I would say that there are also possible issues with screening. So you may all recall that when US Preventive Services Task Force, which is felt to be the most influential in making recommendations for a PSA screening, gave a D recommendation in their most recent iteration of PSA screening, and that is that PSA screening is not recommended for the average person, especially for the older individuals, there was no real recommendation for men of African descent, or African American men. And they are really the ones who are underrepresented in these studies. So in one study, for instance, that looked at rigorous modeling, when they look at these trials, they suggested that PSA screening can actually yield greater mortality benefits for high-risk groups. And that includes men of African American descent. So one other big issue with this is probably access or utilization of health care, which would be a key factor in racial or ethnic disparities. And we know that standard prostate biopsies are still really the gold standard for diagnosis. And whenever we talk about better tools for making diagnosis, and we mentioned earlier about MRIs, for instance, MRIs may be less utilized in patients with lower, let's say, socioeconomic status. So there are a lot of reasons why we are seeing these disparities in men with African American descent. ASCO Daily News: So speaking of research, I'd love to ask you about your current research. You treat patients with bladder, kidney, prostate, and testicular cancers. Is there anything you'd like to highlight today? Dr. Jeanny Aragon-Ching: Yes. So, for instance, we are looking carefully at prostate cancer. And we are very much in tuned with the fact that a lot of men with prostate cancer have genetic variants and genetic and hereditary mutations. So we are looking carefully at the differences between men who present with de novo metastatic disease, and that means at the very first presentation to the medical or health professionals, they already have metastatic disease, versus those who were treated with curative intent treatment and then later on down the line present, unfortunately, with metastatic disease because they were not cured. We would like to further define what the differences is between these two population of patients because the former seems to, unfortunately, do worse. So those are the things that we are highlighting. In bladder cancer, we are very closely following what the outcomes would be for patients who have muscle-invasive bladder cancer. For the longest time, we've known that neoadjuvant chemotherapy followed by cystectomy is one of the gold standards of care for treatment of these patients. So the additional role of immunotherapy in addition to neoadjuvant chemotherapy, that is a key improvement perhaps in the field, especially now that we know that avelumab maintenance has been shown to improve survival for a lot of metastatic bladder cancer patients. And for kidney cancer, one of the key things that we would like to further highlight and improve upon the care is for patients who have high-risk, high-stage kidney cancers. So the standard of care remains to be surgery, but we know that a proportion of them would unfortunately recur with metastatic disease or have disease that comes back later on. So the idea is, can we improve upon these odds by giving them adjuvant therapy? So we have an adjuvant immunotherapy trial that seeks to answer this question of improvement in the [INAUDIBLE], in the metastases or recurrence for these patients who have or are deemed to have high risk disease (NCT03138512). ASCO Daily News: And what is the name of that trial? Dr. Jeanny Aragon-Ching: So this is actually CheckMate 914. This is the neoadjuvant immunotherapy nivolumab and ipilimumab versus a placebo. It's a placebo-controlled trial. ASCO Daily News: Excellent. So Dr. Aragon-Ching, is there anything else on your mind that you'd like to address today before we wrap up the podcast? Dr. Jeanny Aragon-Ching: Yeah. I really just think that the changes in practice brought on by the COVID-19 pandemic has us rethinking and reorganizing as an oncologic community the practice that we do. I believe that some are likely here to stay. So, for instance, the changes in the landscape and practices of treatment, we are really thinking about how long the duration of treatment are we providing. Even clinical trials, since the start of the pandemic, of course, the key issue here is some trials have closed their doors on enrollment. And I think we're starting to pick up on those. Some have limited its enrollment. And I think once we get institutional practices streamlined, and people are in general a little bit more comfortable about exposures because they see that everything is safe, I think we'll be getting back to our routine. But I don't think things are going to go back to the way they were. I think telehealth visits, for instance, are here to stay. We're creating a lot of guidance and guidelines on who are the patients who are best fit for these telehealth monitoring visits, or who are the patients who still need to come in person in order to get their care? ASCO Daily News: Absolutely. Well, Dr. Aragon-Ching, thank you so much for sharing your valuable insight with us today on the ASCO Daily News Podcast. Dr. Jeanny Aragon-Ching: Yeah. Thank you so much, too, Geraldine for having me and for sharing the insights with you all. ASCO Daily News: And thank you to our listeners for joining us today. If you're enjoying the content on the podcast, please take a moment to rate and review us wherever you get your podcasts.   Disclosures: Dr. Jeanny Aragon-Ching Paid Honoraria: Bristol-Myers Squibb, EMD Serono, and Astellas Scientific and Medical Affairs Inc. Consulting or Advisory Role: Algeta/Bayer, Dendreon, AstraZeneca, Janssen Biotech, Sanofi, EMD Serono, AstraZeneca/MedImmune, Bayer, Merck, Seattle Genetics, and Pfizer Speakers’ Bureau: Astellas Pharma, Janssen-Ortho, Bristol-Myers Squibb, and Astellas/Seattle Genetics Travel Paid or Reimbursed: Dendreon, Algeta/Bayer, Bristol Myers Squibb, and EMD Serono Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

In this week’s podcast, Medtech Insight's managing editor Marion Webb discusses how the US Preventive Services Task Force’s recommendations to lower colon screening to age 45 may impact Exact Sciences’ Cologuard stool test. Deputy editor Reed Miller highlights third-quarter results of Stryker, Boston Science and Edwards Lifesciences. Listen to the podcast via the player below: Stryker Sees ‘V-Shape’ Recovery In Third Quarter Boston Scientific Exceeds Wall Street’s Expectations In Q3 Edwards Returns To Growth In The Third Quarter USPSTF Recommendations For Colon Cancer Screening At Age 45 Could Give Cologuard A Boost For more information on Medtech Insight and to start a free trial, click here: http://bit.ly/2w7LnlR Medtech Insight articles addressing topics discussed in this episode:

REGISTER TODAY for this must attend Health Disparities Health Forum here. Big thanks to Donna F. Murray, DMSc., MS, PA-C - Founding Director of Clinical Education, Lenior-Rhyne University, Adjunct Professor, Pfeiffer University and Gardner-Webb, and my fabulous guest for this interview: Susan Rucker, DHA, FACHE, Legislative Board Member for Health Care Justice NC, and Assistant Professor, Queens University of Charlotte. Examples of Health Disparities TODAY that effect our friends, families, neighbors, and loved ones. COVID: African Americans have almost three times more likely to get COVID and two times more likely to die. (CDC August 18, 2020). Infant Mortality: 15.6 African American infant deaths per 1,000 versus 2.5 deaths per 1000 for whites. African Americans, Indian, and Alaska Native (AI/AN) women are two to three times more likely to die from pregnancy-related causes than white women. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm Heart Disease: African Americans are 30 percent more likely than whites to die prematurely from heart disease and African American men are twice as likely as whites to die prematurely from stroke (HHS, 2016b). Moreover, African American and American Indian/Alaska Native females have higher rates of stroke-related death than Hispanic and white women. Colorectal cancer: African Americans have the highest incidence and mortality rates of colorectal cancer (CRC) of any ethnic group in the United States. African Americans bear a disproportionate burden, with an incidence of CRC that is more than 20% higher than in whites and an even larger difference in mortality (ncbi.nlm.hih.gov).ps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5785537/ ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5785537/ REGISTER TODAY for this must attend Health Disparities Health Forum here. Big thanks for our panelist:  Robert Lindsey, Full Professor/Teacher Advisor - Health Education, Johnson C Smith University Elisa (Lisa) Melvin, PhD, MEd, Associate Professor - Health Administration, Pfeiffer University Donna F. Murray, DMSc., MS, PA-C - Founding Director of Clinical Education, Lenior-Rhyne University, Adjunct Professor, Pfeiffer University and Gardner-Webb Check this out!!!!! The featured speaker is Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, is also former Administrator of the Centers for Medicare & Medicaid Services under the Obama Administration. A pediatrician by background, Dr. Berwick has served on the faculty of the Harvard Medical School and Harvard School of Public Health, and on the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. He has also served as Vice Chair of the US Preventive Services Task Force, the first "Independent Member" of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality. See omnystudio.com/listener for privacy information.

henry ford once said “failure is simply the opportunity to begin again, this time more intelligently” Designed to Fail? the Future of Primary Care Journal of General Internal Medicine (2020) Access to primary care has been shown to improve patient outcomes and lower cost although outcomes are debated the cost is not- its because we can be the jack of all or the referral of all. neither is wrong the authors in this paper analyzed the 2019 “in-basket” activity of our clinical faculty at the University of Michigan to determine the average weekly activity by category of EMR tasks. A full-time primary care faculty member had a total of 390 in-basket tasks per week or 17,542 in-basket tasks per year. they surveyed 56 clinicians, and asked how much time, to the nearest minute, they spent on in-basket tasks: and a median time of 1199 min (~ 20 h) per week on these tasks many task require further steps- like addressing lab work, or ordering follow up imaging, or doing a prior authorization ALL of which are unpaid. essentially PCP see patients full time then have another part time job they do for free in answering inbox messages and we wonder why pcp is a dying speciality that no one wants to go into. a change is needed onto the next article I have said many times that I love an article that answers a simple question The Journal of Sexual Medicine Are We Overstating the Risk of Priapism With Oral Phosphodiesterase Type 5 Inhibitors? J Sex Med 2020 Jul 01;[EPub Ahead of Print], ME Rezaee, MS Gross Viagra and cialis have the famous saying on their commericial to consult a dr. if you have an erection lasting longer than 4 hours. Well in this study they looked to answer the question how often does this actually occur! They evaluated all cases of priapism reported to the FDA since 1998 which happens to be when viagra hit the market and they were able to identify a total of 411 cases due to Phosphodiesterase Type 5 Inhibitors Now it is hard to get exact or precise numbers on number of viagra and cialis prescriptions out there but In the first year and a half of marketing in the United States, more than 15.6 million prescriptions of Viagra had been filled. So even if there was not another single script of Viagra written for and we just went based on the first year and a half and we assumed each prescription was for only 3 pills then the rate of priapism would be 411/46.8million which in % terms comes out to 0.0008%-- basically nothing!! And that is just the first year scripts, obviously the numbers are much larger and we are over exaggerating the evidence. Although PDE5i-induced priapism does occur, it appears less common than once suspected. When counseling patients, this should be considered. Dean martin once said “Everybody loves somebody sometime” well it appread in medicine Everyone wants to treat subclinical hypothyroidism sometime – Clearly seen in this paper -- https://jamanetwork.com/journals/jama/fullarticle/2768464?guestAccessKey=cafa97b4-33a8-49f3-9c5c-df1ebf349f84&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=072120 Effect of Levothyroxine on Left Ventricular Ejection Fraction in Patients With Subclinical Hypothyroidism and Acute Myocardial InfarctionA Randomized Clinical Trial Where they sought to find if levothyroxine treatment improved left ventricular function in patients with subclinical hypothyroidism presenting with acute myocardial infarction? A double-blind, randomized clinical trial took 95 participants with subclinical hypothyroidism and acute myocardial infarction, treatment with levothyroxine, compared with placebo Levothyroxine treatment (n = 46) started at 25 µg titrated to aim for a TSH levels between 0.4 and 2.5 mU/L And after 52 weeks-the authors nailed it when they say- “treatment with levothyroxine, compared with placebo, did not significantly improve left ventricular ejection fraction after 52 weeks." Don't trust the person who has broken faith once.” – William Shakespeare. But I think what he meant to say was don’t trust a medical journal abstract--- clearly seen in https://www.acpjournals.org/doi/10.7326/M20-0289 Sodium–Glucose Cotransporter-2 Inhibitors and the Risk for Diabetic Ketoacidosis A Multicenter Cohort Study In the abstract they say Conclusion: SGLT-2 inhibitors were associated with an almost 3-fold increased risk for DKA, with molecule-specific analyses suggesting a class effect They looked at Electronic health care databases from 7 Canadian provinces and the United Kingdom and found a total of over 400,000 pateints on either a ddp4 or sglt2- mean follow up was almost one year. And during this time out of all those people there were only 521 cases of DKA. And if you just go by the numbers then risk for DKA was 2 per thousand for the SGLT2 inhibitors and was 0.75 per 1000 person-years for the DDP4 inhibitors. A three fold increase is scary! But the fact that no DDP4 has ever shown to be beneficial ofr the outcomes I care about like MACE and chronic kidney disease I think I and all my patients will take their chances. Mr jones I can give you a medication that will put you in the hospital once every 500 yrs but out of every 20-50 people that take it we will prevent a heartattack or a death or a renal failure or a stroke Or I can give you a drug that will only put you in the hospital for dka once every 1000 years but have never been shown to do anything. What would you like to do?? This is a strawman argue and a terrible comparible arm and a gentle and continued reminder to always question medicine and don’t trust the abstract Reference US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and adults. US Preventive Services Task Force recommendation statement. JAMA 2020;323(10):970-975. These recommendations replace the previous 2013 USPSTF recommendation of screening adults born between 1945 and 1965 In this updated 2020 review, the U.S. Preventive Services Task Force (USPSTF) found adequate evidence that hepatitis C virus (HCV) screening accurately detects HCV infection. Although there is no direct evidence on the benefit of screening for HCV infection on patient-oriented outcomes, there is convincing evidence that treatment results in a high proportion (95.5% - 98.9%) of adults who maintain a sustained virologic response (SVR), with a strong association between SVR and improved health outcomes. The task force also recommends screening for HCV in all pregnant women. now is time when we have annual exam worth something hep c screening and hiv screening for everyone

Nesse episódio, João, Fred e Iago voltam com um quadro antigo do Podcast: Paciente pergunta! Dessa vez pra trazer as evidências em relação ao uso de vitaminas: Benefícios? Malefícios? Em quais pacientes vale mais a pena? Ouça tudo isso nesse episódio. Compartilha com a gente a sua experiência e dúvidas através do Instagram ou Twitter em @tadeclinicagem! Aproveita e assina a nossa newsletter! MINUTAGEM: [02:15] Experiências pessoais com multivitamínicos [07:20] Multivitamínicos em pessoas saudáveis [10:20] Vitaminas e COVID-19 [13:23] Vitamina C e resfriado [18:36] Vitaminas e efeitos adversos [31:06] Populações específicas [44:54] Salves [45:40] Resposta desafio anterior [46:33] Desafio da semana REFERÊNCIAS: 1. http://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/34380639/do1-2018-07-27-instrucao-normativa-in-n-28-de-26-de-julho-de-2018-34380550 - Órgão: Ministério da Saúde/Agência Nacional de Vigilância Sanitária INSTRUÇÃO NORMATIVA - IN N° 28, DE 26 DE JULHO DE 2018 2. GUALLAR, Eliseo et al. Enough is enough: stop wasting money on vitamin and mineral supplements. Annals of internal medicine, v. 159, n. 12, p. 850-851, 2013. 3. MOYER, Virginia A. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: US Preventive Services Task Force recommendation statement. Annals of internal medicine, v. 160, n. 8, p. 558-564, 2014. 4. BJELAKOVIC, Goran et al. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane database of systematic reviews, n. 3, 2012. 5. HEMILÄ, Harri; CHALKER, Elizabeth. Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews, n. 1, 2013. 6. THOMAS, Laura DK et al. Ascorbic acid supplements and kidney stone incidence among men: a prospective study. JAMA internal medicine, v. 173, n. 5, p. 386-388, 2013. 7. FESKANICH, Diane et al. Vitamin A intake and hip fractures among postmenopausal women. Jama, v. 287, n. 1, p. 47-54, 2002. 8. MILLER III, Edgar R. et al. Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Annals of internal medicine, v. 142, n. 1, p. 37-46, 2005. 9. OMENN, Gilbert S. et al. Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. New England journal of medicine, v. 334, n. 18, p. 1150-1155, 1996. 10. Aarts, E. O., et al. "Prevalence of anemia and related deficiencies in the first year following laparoscopic gastric bypass for morbid obesity." Journal of obesity 2012 (2012). 11. Damms-Machado, Antje, et al. "Pre-and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy." Obesity surgery 22.6 (2012): 881-889. 12. Ledoux, Séverine, et al. "Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass." Obesity surgery 16.8 (2006): 1041-1049. 13. Achamrah, Najate, et al. "Micronutrient status in 153 patients with anorexia nervosa." Nutrients 9.3 (2017): 225. 14. Adams, Kathleen K., William L. Baker, and Diana M. Sobieraj. Myth Busters: Dietary Supplements and COVID-19." Annals of Pharmacotherapy (2020): 1060028020928052. 15. Manson, JoAnn E., and Shari S. Bassuk. "Vitamin and mineral supplements: what clinicians need to know." Jama 319.9 (2018): 859-860. 16. Cohen, Pieter A. "The supplement paradox: negligible benefits, robust consumption." Jama 316.14 (2016): 1453-1454.

We have learned a great deal recently about maintaining your health. The US Preventive Services Task Force recommends all Americans ages 18-79 be screened for Hepatitis C. A review indicates mammography doesn’t save lives after age 75. There are at least 7 things you can do to lower your risk of dying of cancer. We explain what you need to do with this information, and discuss the future of Alexa in a jam-packed hour of radio.

Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Larissa Korde whose research interests focus on breast cancer treatment and prevention at the National Institutes of Health. Today we're talking about breast cancer screening as it relates to bracket gene mutations. Dr. Korde, welcome to the podcast. Thank you for having me. We're glad you're here. Although 12% of women in the United States will develop breast cancer sometime during their lives, approximately 72% of women who inherit the BRCA1 mutation and about 69% of women who inherit the BRCA2 mutation will develop breast cancer by the age of 80. Recently the US Preventive Services Task Force expanded the recommendation of patients who should be screened for the BRCA1 and BRCA2 genetic mutation, which is associated with multiple cancer types. How did this update come about? The US Preventive Services Task Force last presented guidelines on this topic in 2013. The recent publication in the Journal of the American Medical Association is an update, and it reviews the evidence that has come about since 2013. It's important to note that these recommendations are not actually about who should be tested for BRCA1 or 2 mutations. What the recommendations address is really who should be screened and that screening would be evaluation of family history. So the screening with family history is designed to identify which patients should be referred for further evaluation by a provider experience in genetic counseling and testing who can then make recommendations regarding actually having a gene test. The task force recommends that primary care providers assess women with a personal or family history of breast or ovarian cancer and ovarian includes fallopian tube and peritoneal cancers. And they also recommend that those who have an ancestry associated with a BRCA1 or 2 mutation should be assessed using a family history assessment tool. There are a number of brief assessment tools that can be used in the clinic setting and are designed to assist providers in identifying which patients should be referred for genetic counseling and then if appropriate for genetic testing. Also the task force recommends against routine assessment and referral in patients that do not meet their set criteria. The important update is that compared to the 2013 guideline, the population for whom risk assessment is deemed appropriate is broader, and specifically it's been expanded to include those women with a personal history of breast or ovarian cancer and those with a specific ancestry. The ancestry part of this was met to increase awareness of the strong association between BRCA1 and 2 mutations in Ashkenazi Jewish ancestry. Again, though, this is not a blanket recommendation that all women of Ashkenazi Jewish ancestry should be tested for BRCA1 and 2 mutations, just that the knowledge of ancestry should consider-- that should trigger additional evaluation. There are certainly schools of thought that a more inclusive approach is needed. For example, there are folks who advocate for universal mutation testing in all women with breast cancer or all women with Ashkenazi Jewish descent while others favor a more targeted approach. These recommendations call for the more targeted and step-wise approach. So the first step would be evaluation of personal and family history and ancestry followed by referral of patients that meet a certain threshold of risk. And then finally followed by testing if it's appropriate after counsel. That's great. Sounds like it's a lot more about finding out who really needs to be tested and not so much about the test itself. So how can this update improve outcomes for patients? Well, I think the basic goal here is that if we can do a better job at identifying who to screen for the BRCA1 and 2 mutation, then we can do a better job of offering appropriate interventions to those who take the test and test positive. And that can take many forms. The most obvious here is that those who have the highest likelihood of having the BRCA mutation will be referred for the appropriate counseling, and then they can make the decision with the advice of their providers about whether or not to undergo testing. And, of course, there are also downstream effects. Once a patient is identified as having a BRCA mutation, she can be offered preventive interventions such as prophylactic mastectomy or [INAUDIBLE], and she can be offered more intensive cancer screening. It's important to note here that the recommendations were expanded to include women with a personal history of cancer because we know that these women are at risk for developing a second cancer. And that's important information, particularly for a patient whose original cancer was treated with curative intent. Something that was outside of the scope of this guideline but which I think is becoming increasingly important in the oncology community is that [INAUDIBLE] genetic information can now be used to select therapies for patients with cancer. Specifically PARP inhibitors are FDA approved for treatment of metastatic breast cancer in women with a germline BRCA mutation and are being studied in other cancers and also in the earlier stage study. So this information clearly has treatment implications. Lastly, the identification of patients that carry a BRCA mutation leads to what we call cascade testing. That is once you know someone has the mutation, you can offer mutation testing to their family members, and those who test positive can be offered appropriate intervention. I think that this is definitely a benefit. That sounds very promising. Do you have any concerns about the new guidelines in terms of how they will be interpreted? No real concerns about how the guidelines will be interpreted. I think they're pretty straightforward, and they do help to expand the population who should be eligible for testing or at least screen for referral to a genetic counselor. So I think it's important here to note that there's a lot of issues in genetic screening and testing that the guidelines do not address, primarily because there are not enough data on which to base recommendations. These are issues that I think will become more pressing in the future and hopefully can be addressed in future guidelines. One important issue with multi-gene panel testing. Since the guideline doesn't explicitly state what gene testing should occur, just that patients should be screened and referred, it does not get into which test should be used once someone is identified having it-- identified as having a high enough risk of carrying a mutation to be referred. Multi-gene panels are becoming increasingly prevalent, and there's a lot of variation in which genes are included in panels and even in whether a particular abnormality found is classified as a deleterious mutation, as a variant of uncertain significance, or as a benign polymorphism. Also some panels contain genes for which they're not clear clinical implications in terms of what cancer screening or preventive interventions should be offered to patients who carry these genes. So while this is outside of the scope of the guidelines, I think it's important because the information in the guideline is geared towards primary care providers. And so when they make a referral for genetic screening and testing, they need to be aware of the downstream consequences and particularly about how to counsel and treat a patient who is found to have the mutation other than BRCA1 or 2. This is something that's going to come up in clinical practice, and so I think it's important for providers to be educated about the range of possibilities. The other issue that I want to raise, which again is not addressed in the guidelines due to a lack of available data but which is nonetheless important for providers to be aware of, is direct to consumer testing. For example, one of the very kind of consumer panels that you see on TV all the time includes evaluation for one of the [INAUDIBLE] mutations in BRCA1 and 2 that are prevalent in the Ashkenazi Jewish population. So you could imagine a scenario where a patient with a strong family history comes in and she's asked about her family history of breast or ovarian cancer and then just says, oh, I already have the gene test. It was negative. And what that patient may mean is that they did this direct to consumer panel, and they don't have one of the three [INAUDIBLE] mutations. But it's not comprehensive testing. So if the family history is indicative, this person should still be referred to a genetics provider for counseling and testing that would include looking for all the possible mutations in BRCA1 and 2, not just these three [INAUDIBLE] mutations and possibly looking at other genes associated with breast and ovarian cancer as well. So without a working knowledge about what tests are out there, this is a patient who could be missed or who could be counseled inappropriately. That's a very important distinction. What should clinicians tell their patients who have questions or perceptions about over testing? I don't think these guidelines will lead to over testing. They identify appropriate specific populations of women that should be referred for a more thorough genetic evaluation. And the end result there is a referral for more information, not necessarily a test. After meeting with the genetic counselor, the patient can make an informed decision about whether or not to pursue testing and then about what type of testing to do. Actually I think under testing is much more of a problem-- is much more the problem that we currently face. Susan [INAUDIBLE] pointed out in her editorial that accompanied the Preventive Services Task Force recommendation that although it's estimated that about 15% of women with ovarian cancer have a BRCA mutation, studies have shown that less than 30% of such patients were tested. So the inclusion of women with a personal history of cancer in these guidelines is definitely an important step forward. Under testing is also a substantial issue in underrepresented minorities and those with a lower socioeconomic status. Access to care is an issue for those living in rural areas, and this is a problem that might be alleviated through things like telegenetics. I was listening to a talk yesterday about health disparities and how telemedicine might be helpful, and the speaker said that any provider interaction that does not require a physical exam can be done through telemedicine. I think that's true of genetic counseling. There are also ongoing studies evaluating alternative models providing genetic education and counseling, and I think these will become increasingly important in the future and can hopefully help to address the issue of under testing. Absolutely. What an important point. Again today my guest has been Dr. Larisa Korde. Thank you so much for being on our podcast today. It's my pleasure and thank you for having me. And to our listeners, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content, we encourage you to subscribe, rate us, and review us on Apple podcasts. Also to listen to ASCO's other offerings, please visit ASCO.org/podcast.

Rochelle P. Walensky, MD, MPH joins JAMA Network editors to discuss the importance of the US Preventive Services Task Force recommendation statements on HIV screening and preexposure prophylaxis (PrEP). Read the article here: https://ja.ma/2NsZ9K4. JNO Live is a weekly broadcast featuring conversations about the latest research being published in JAMA Network Open. Follow us on Facebook, Twitter and YouTube for details on the next broadcast.

Heute geht es innerhalb einer kleinen Serie zu Ernährung um das Thema Nahrungsergänzungsmittel (v.a. Vitamine, Mineralien und sogenannte Mikronährstoffe): Vitaminmangel: Irrtum oder bewusste Desinformation?  //   Ein riesiger, kaum kontrollierter Wirtschaftszweig USA: 30 Mrd. US$, 90.000 Produkte. 52% der Erwachsenen ≥1 NEM, 10% ≥4 NEM Kantor  ED, Rehm  CD, Du M, White  E, Giovannucci EL.  Trends in dietary supplement use among US adults from 1999-2012.  JAMA. 2016;316(14):1464-1474. Deutschland:1.44 Milliarden € und steigend, 225 Mio. Packungen/J Vitamine und Mineralien von 48% bzw 39% eingenommen. UngeprüftVor Markteinführung von Behörden weder Wirksamkeit noch Sicherheit. https://www.verbraucherzentrale.de/aktuelle-meldungen/lebensmittel/endlich-klartext-bei-nahrungsergaenzungsmitteln-13409 Was?Reine Mineralien (Magnesium oder Calcium) (53,2 Mio. Packungen) Vitamin C (29,2 Mio. Packungen) Multivitamin ± Mineralien (24,7 Mio. Packungen) Vitamin B12 oder B-Komplex (9,9 Mio. Packungen) Vitamin A/D rein oder kombi (5,7 Mio. Packungen) Wo?41,4% Drogerie 32,5% Lebensmitteleinzelhandel 7,3 % Versand 19,2% Apotheke (also ⅘ ohne Beratung, auch WW) https://www.bll.de/de/verband/organisation/arbeitskreise/arbeitskreis-nahrungsergaenzungsmittel-ak-nem/20181029-zahlen-nahrungsergaenzungsmittel-markt-2018 Sinnvoll?Gesundheit beizubehalten und Krankheit zu verhindern = Primär- oder Sekundärprävention chronischer Krankheiten? Multivitamin- / Multimineral-Supplementation Nicht empfohlenDie meisten randomisierten klinischen Studien mit Vitamin- und Mineralstoffzusätzen keine eindeutigen Vorteile. Für allgemein gesunde Erwachsene nicht empfohlen. Moyer  VA; US Preventive Services Task Force.  Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: US Preventive Services Task Force recommendation statement.  Ann Intern Med. 2014;160(8):558-564. SchädlichHohe Dosen Beta-Carotin, Folsäure, Vitamin E oder Selen schädlich: erhöhter Sterblichkeit, Krebs Schlaganfall Rautiainen  S, Manson JE, Lichtenstein  AH, Sesso HD. Dietary supplements and disease prevention: a global overview.  Nat Rev Endocrinol. 2016;12(7):407-420. Besser aus gesunder, ausgewogener ErnährungNEM kein Ersatz für gesunde ausgewogene Ernährung. Mikronährstoffe in Lebensmitteln in der Regel besser aufgenommen plus weniger potenzielle Nebenwirkungen Rautiainen  S, Manson JE, Lichtenstein  AH, Sesso HD. Dietary supplements and disease prevention: a global overview.  Nat Rev Endocrinol. 2016;12(7):407-420 Marra  MV, Boyar  AP. Position of the American Dietetic Association: nutrient supplementation.  J Am Diet Assoc. 2009;109(12):2073-2085. Alle wichtigen Substanzen in biologisch optimalen Verhältnissen im Gegensatz zu isolierten Verbindungen in hochkonzentrierter Form. Gesundheit hängt stärker mit Ernährungsgewohnheiten und Lebensmittelarten zusammen, als mit der Aufnahme einzelner Mikronährstoffe oder Nährstoffe. Marra  MV, Boyar  AP. Position of the American Dietetic Association: nutrient supplementation.  J Am Diet Assoc. 2009;109(12):2073-2085. Vit. A, C (im Urin), E damit thematisch schon abgehandelt; nicht sinnvoll. Vitamin KKann Wirksamkeit bestimmter Blutverdünner / Gerinnungshemmer mindern Wann sinnvoll?Wenn klare Ernährungsdefizite medizinisch nachgewiesen: Hoch-Risiko-Gruppen Bestimmten Lebensphasen Ernährungsbedürfnisse nicht allein durch die Ernährung gedeckt Bestimmten Risikofaktoren/Erkrankungen LebensphasenSchwangerschaft: Folsäure Säuglinge und Kinder: Gestillte Säuglinge Vitamin D bis zum Absetzen Eisen 4.-6. Monat wenn Fe haltige Nahrung beginnt Mittlere und ältere Erwachsene: Evtl. Vitamin B12 Hohes RisikoEssverhalten eingeschränkt Nährstoffaufnahme oder Stoffwechsel beeinträchtigt: Bariatrische oder Adipositas-Chir...

Dr. Donald M. Berwick served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry and later as the Administrator of Medicare and Medicaid under President Obama.Having started his career as a Harvard-educated pediatrician and expert on medical policy, Dr. Berwick left the daily practice of medicine in 1989 to launch the Institute For Healthcare Improvement, an organization that now collaborates with hospitals and institutions around the world.He continues to serve on many committees, including as Vice Chair of the US Preventive Services Task Force and the first "independent member" of the American Hospital Association Board of Trustees.In addition to serving for two terms on the Institute of Medicine's (IOM's) Governing Council and member of the IOM's Global Health Board, Dr. Berwick has done extensive work with the Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital.Dr. Berwick is the author or co-author of over 160 scientific articles and six books, he currently serves as Lecturer in the Department of Health Care Policy at Harvard Medical School. In 2014 he also was a Democratic candidate for governor of Massachusetts

Dr. Donald M. Berwick served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry and later as the Administrator of Medicare and Medicaid under President Obama.Having started his career as a Harvard-educated pediatrician and expert on medical policy, Dr. Berwick left the daily practice of medicine in 1989 to launch the Institute For Healthcare Improvement, an organization that now collaborates with hospitals and institutions around the world.He continues to serve on many committees, including as Vice Chair of the US Preventive Services Task Force and the first "independent member" of the American Hospital Association Board of Trustees.In addition to serving for two terms on the Institute of Medicine's (IOM's) Governing Council and member of the IOM's Global Health Board, Dr. Berwick has done extensive work with the Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital.Dr. Berwick is the author or co-author of over 160 scientific articles and six books, he currently serves as Lecturer in the Department of Health Care Policy at Harvard Medical School. In 2014 he also was a Democratic candidate for governor of Massachusetts

Dr. Donald M. Berwick served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry and later as the Administrator of Medicare and Medicaid under President Obama.Having started his career as a Harvard-educated pediatrician and expert on medical policy, Dr. Berwick left the daily practice of medicine in 1989 to launch the Institute For Healthcare Improvement, an organization that now collaborates with hospitals and institutions around the world.He continues to serve on many committees, including as Vice Chair of the US Preventive Services Task Force and the first "independent member" of the American Hospital Association Board of Trustees.In addition to serving for two terms on the Institute of Medicine's (IOM's) Governing Council and member of the IOM's Global Health Board, Dr. Berwick has done extensive work with the Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital.Dr. Berwick is the author or co-author of over 160 scientific articles and six books, he currently serves as Lecturer in the Department of Health Care Policy at Harvard Medical School. In 2014 he also was a Democratic candidate for governor of Massachusetts

Interview with Elizabeth O'Connor, PHD, author of Interventions to Prevent Perinatal Depression: Evidence Report and Systematic Review for the US Preventive Services Task Force

Every week, The American Journal of Managed Care® recaps the top managed care news of the week, and you can now listen to it on our podcast, Managed Care Cast. This week, the top managed care news included a panel mostly endorsed the use of patient-reported outcomes for coverage of chimeric antigen receptor T-cell therapy; the US Preventive Services Task Force released new recommendations for cervical cancer screening; research found accountable care organization penetration may be changing how physicians work. Read more about the stories in this podcast: Many Questions to Ask in Setting National Coverage for CAR T Therapies: https://www.ajmc.com/focus-of-the-week/many-questions-to-ask-in-setting-national-coverage-for-cart-therapies MEDCAC Panel Mostly Endorses PROs for CAR T Therapies: https://www.ajmc.com/newsroom/medcac-panel-mostly-endorses-pros-for-car-t-therapies USPSTF Updates Cervical Cancer Screening Recommendations: https://www.ajmc.com/newsroom/uspstf-updates-cervical-cancer-screening-recommendations ACO Penetration Linked to Decreased Work Hours, Less Self-Employment: https://www.ajmc.com/focus-of-the-week/aco-penetration-linked-to-decreased-work-hours-less-selfemployment Substituting Brand-Name Combinations for Generics Could Have Saved Medicare $925 Million in 2016: https://www.ajmc.com/focus-of-the-week/substituting-brandname-combinations-for-generics-could-have-saved-medicare-925-million-in-2016 Payment Reform Reveals Value of Diabetes Educators in Driving Down Healthcare Costs, Joslin's Gabbay Says: https://www.ajmc.com/conferences/aade2018/payment-reform-reveals-value-of-diabetes-educators-in-driving-down-healthcare-costs-joslins-gabbay-says American Association of Diabetes Educators 2018: https://www.ajmc.com/conferences/aade2018 Evidence-Based Oncology—August 2018: https://www.ajmc.com/journals/evidence-based-oncology/2018/august-2018

From self-described army brat to a renowned physician and scientist, Dr. Kirsten Bibbins-Domingo's career success is due in part to her many interests and her ability to pursue a job in which she could thrive. Her thoughts apply to anyone committed to hard work and a balanced life, no matter the field. In this conversation with Dr. Robert Wachter, Chair of the UCSF Department of Medicine, we learn how she is helping to shape healthcare through her work both at UCSF and as the immediate past-chair of the US Preventive Services Task Force, which makes evidence-based recommendations about services such as screenings, counseling services, and preventive medications. Series: "A Life in Medicine: People Shaping Healthcare Today" [Health and Medicine] [Business] [Education] [Professional Medical Education] [Show ID: 32620]

From self-described army brat to a renowned physician and scientist, Dr. Kirsten Bibbins-Domingo's career success is due in part to her many interests and her ability to pursue a job in which she could thrive. Her thoughts apply to anyone committed to hard work and a balanced life, no matter the field. In this conversation with Dr. Robert Wachter, Chair of the UCSF Department of Medicine, we learn how she is helping to shape healthcare through her work both at UCSF and as the immediate past-chair of the US Preventive Services Task Force, which makes evidence-based recommendations about services such as screenings, counseling services, and preventive medications. Series: "A Life in Medicine: People Shaping Healthcare Today" [Health and Medicine] [Business] [Education] [Professional Medical Education] [Show ID: 32620]

  Dr. Lam:               Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the Journal and its editors. I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Our podcast is taking us to Japan today where we will be talking about aspirin for primary prevention in patients with diabetes. First, here's your summary of this week's issue.                                 The first study provides insight into the development of neurologic injury in patients with single ventricles undergoing staged surgical reconstruction. In this paper by Dr. Fogel and colleagues from the Children's Hospital of Philadelphia, the authors recognize that single ventricle patients experience greater survival with staged surgical procedures culminating in the Fontan operation, but experience high rates of brain injury and adverse neurodevelopmental outcome. They therefore studied 168 single ventricle patients with MRI scans immediately prior to bi-directional Glenn, prior to the Fontan, and then three to nine months after the Fontan reconstruction. They found that significant brain abnormalities were frequently present in these patients and that the detection of these lesions increased as children progressed through staged surgical reconstruction. In addition, there was an inverse association of various indices of cerebral blood flow with these brain lesions. This study therefore suggests that measurement of cerebral blood flow and identification of brain abnormalities may enhance recognition of single ventricle patients at risk for poor outcomes, and possibly facilitate early intervention.                                 The next paper uncovers a unique mechanism underlying arrhythmogenesis and suggests that the anti-epileptic drug valproic acid may possibly be repurposed for anti-arrhythmic applications. In this paper by first authors Dr. Chowdhury and Liu and corresponding author Dr. Wang and colleagues from University of Manchester UK. The authors used mouse models and human induced pluripotent stem cells derived cardiomyocytes to discover a new mechanism linking mitogen activated kinase-kinase 7 deficiency with increased arrhythmia vulnerability in pathologically remodeled hearts. Mechanistically, mitogen activated kinase-kinase-7 deficiency in the hypertrophied hearts left histone deacetylase-2 unphosphorylated, and filamin A accumulated in the nucleus, which then formed an association with kruppel-like factor 4 preventing its transcriptional regulation. Diminished potassium channel reserve caused repolarization delays resulting in ventricular arrhythmias, and the histone deacetylase-2 inhibitor, valproic acid restored potassium channel expression abolishing the ventricular arrhythmias. This study therefore provides exciting insights in developing a new class of anti-arrhythmics specifically targeting signal transduction cascades to replenish repolarization reserve, all for the treatment of ventricular arrhythmias.                                 Does the Mediterranean diet improve HDL function in high risk individuals? Well, the next paper by first author Dr. Hernaiz, corresponding author Dr. Fito and colleagues from Hospital Del Mar Medical Research Institute in Barcelona, Spain addresses this questions. The authors looked at a large sample of 296 volunteers from the PREDIMED study and compared the effects of two traditional Mediterranean diets, one enriched with virgin olive oil, and the other with nuts to a low-fat control diet. They looked at the effects of these diets on the role of HDL particles on reverse cholesterol transport, HDL antioxidant properties, and HDL vasodilatory capacity after one year of dietary intervention. They found that both Mediterranean diets increased cholesterol efflux capacity and improved HDL oxidative status relative to the baseline. In particular, the Mediterranean diet enriched with virgin olive oil decreased cholesterol ester transfer protein activity, and increased HDL ability to esterify cholesterol, paraoxonase-1, arylesterase activity, and HDL vasodilatory capacity. They therefore concluded that adherence to a traditional Mediterranean diet, particularly when enriched with virgin olive oil, improves HDL function in humans.                                 The final study tells us that among hospitalized medically ill patients, extended duration Betrixaban reduces the risk of stroke compared to standard dose enoxaparin. In this retrospective sub-study of the APEX trial, Dr. Gibson and colleagues from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts randomized 7,513 hospitalized acutely ill patients in a double-dummy, double-blind fashion to either extended duration of the oral Factor Xa inhibitor Betrixaban at 80 mg once daily for 35 to 42 days, or standard dose subcutaneous enoxaparin at 40 mg once daily for 10 days all for venous thromboprophylaxis. They found that the extended duration Betrixaban compared with enoxaparin reduced all cause stroke by almost one half with a relative risk of 0.56 equivalent to an absolute risk reduction of 0.43 percent and number needed to treat of 232. The effect of Betrixaban on stroke was explained by a reduction in ischemic stroke with no difference in hemorrhagic stroke. The reduction in ischemic stroke was confined to patients hospitalized with acute heart failure or non-cardioembolic ischemic stroke.                                 This paper is accompanied by an editorial by Drs. Quinlan, Eikelboom, and Hart in which they articulate three reasons that they think these results are important. First, the results demonstrated an unexpectedly high rate of new or recurrent ischemic stroke during the first three months in hospitalized medical patients receiving standard enoxaparin prophylaxis, the rate being even higher in patients presenting with heart failure or ischemic stroke. Secondly, the data demonstrated for the first time that a NOAC reduces the risk of ischemic strokes in patients without known atrial fibrillation. Thirdly, the effects of Betrixaban on stroke were dose dependent, all of the benefits were seen in those who received the 80 mg dose, whereas the 40 mg dose did not provide advantages compared with enoxaparin or placebo. While these results are encouraging, the editorialists also warn that these are based on a post-hoc analysis and should be considered hypothesis generating.                                 Well, that brings it to the end of our summaries. Now for our feature discussion.                                 Today our feature discussion focuses on the exciting 10-year follow up results of the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes, or JPAD trial. I am simply delighted to have with me first and corresponding author Dr. Yoshihiko Saito from Nara Medical University, Japan. As well as a familiar voice on this podcast, Dr. Shinya Goto associate editor of Circulation from Tokai University in Japan. Welcome gentlemen! Dr. Goto:             I am very pleased to have this opportunity. I am always enjoy listening your podcast, and this is very interesting topic of aspirin in prevention cardiovascular event in patients with diabetes, type II diabetes. Dr. Lam:               I couldn't agree more, because the burden of cardiovascular disease globally is actually shifting to Asia, and the burden of diabetes especially, is one of the fastest growing in Asia. So a very, highly relevant topic indeed. Could I start, Yoshi, by asking you: these are the 10 year follow up results, what inspired you to take a re-look at the original JPAD results and to report this 10 year result? Dr. Saito:              The American guidelines said that low-dose aspirin is recommended to the type II diabetes patient for the primary prevention of cardiovascular events who are older than 30 years old, and who are not contraindicated to aspirin. That meant that almost all type II diabetes patients were recommended to low dose aspirin. However, at that time there was no direct [inaudible 00:09:49] evidence for it. So we connected the prospective randomized control trial that examined the effects of the low dose aspirin on primary prevention of cardiovascular events in type II diabetes patients without preexisting cardiovascular disease. The name of this trial, JPAD trial, that stand for the Japanese Primary Prevention of Atherosclerosis with aspirin in Diabetes. We enrolled 2,539 patients who were assigned to the low dose asprin group or the no aspirin group. So we followed them with a median follow up period of 4.4 years.                                 The results of the original JPAD trial were that low dose aspirin reduced CV events by about 20%, but the reduction could not reach statistical significance. So I don't know the exact reason, but one is the reason is low statistical power, because event rate was about one-third of the anticipated. Another reason is that low dose aspirin really could not reduce cardiovascular events. So we decided the extension of the follow up of the JPAD trial to elucidate the efficacy and safety of long term therapy with low dose aspirin in type II diabetes patients. This extension study was named the JPAD 2 study. We followed them up to the median follow up period of more than 10 years.                                 In this time the JPAD trial study, we analyzed the patients in a pod protocol method because the randomized control trial was ended after 2008. Finally, we analyzed the 992 patients in the aspirin group, and 1,168 patients in the no aspirin group who retained the original allocations throughout the study period. The primary endpoint were composite endpoint of cardiovascular events including sudden cardiac death, the fatal and the non-fatal coronary artery disease, fatal and non-fatal stroke, peripheral vascular disease, and aortic dissection. This end point is the same as the original JPAD trial. The main results are the primary endpoints, 15.2% of patients occurred primary endpoints in aspirin group, and 14.2% in the no aspirin group occurred in the primary endpoints. So the primary endpoints rate is singular in both groups, with the hazard ratio is 1.14 with a 95% CI is 0.91 to 1.42 with a p value of 0.2 by log-rank test. So the low dose aspirin therapy could not reduce cardiovascular events in the type II diabetes mellitus.                                 We also analyzed these data by intention to treat analysis, the results is singular. Again, the low dose aspirin therapy could not reduce the cardiovascular event in type II diabetes mellitus. However, I was told the hemorrhagic events, total hemorrhagic events was singular in both groups, but gastrointestinal bleeding of about 2% in the aspirin group but only 0.9% in no aspirin group. That means our gastrointestinal bleeding is doubled in the aspirin group compared with no aspirin group. This is the main outcome of the JPAD and JPAD-2 trials. Dr. Lam:               Thank you so much Yoshi, and really congratulations on such a tremendous effort. I completely applaud the idea of looking at the 10 year follow up trying to address the issue of whether or not it was a lack of power that limited JPAD-1, but what you found really reinforced what you found in JPAD-1, which is low dose aspirin did not reduce cardiovascular events in the diabetic group. They're still huge numbers, I'm so impressed that 85% of the treatment assignment was retained. Then furthermore you even showed increased gastrointestinal bleeding with aspirin. So really remarkable results. Can I just ask, are you surprised by the results, and how do you reconcile it with what was found in the general population studies like the Physician Health Study, or the US Preventive Services Task Force, where they really seem to say that primary prevention aspirin works in the general population when your risk is a certain amount? Dr. Saito:              I think that we studied only the type II diabetes patients, so it is not clear that our results are applied to the general population, but our results is very much similar to the current European guidelines and American guidelines. Dr. Lam:               That's a very interesting point about diabetic versus non-diabetic population and the utility of low dose aspirin. Shinya, you brought this up before. What do you think? Dr. Goto:             For the primary prevention population cohort study, aspirin demonstrated 25% reduction of cardiovascular event. We are not recommending aspirin for primary prevention due to the balance of bleeding and cardiovascular protection, absolute risk. In Yoshi's paper, in patients with type II diabetes aspirin evened that [inaudible 00:16:13], and that is very important message he had shown in this long term outcome randomized trial. Dr. Lam:               Do you think that there are some pathophysiologic differences when you study a diabetic versus non-diabetic population? Dr. Goto:             Yes, that is a very important topic, and we have very nice review paper by Dr. Domenico and Fiorito. In patients with diabetes the platelet time over becomes relatively rapid as compared to general population. New platelets come to blood and COX-1 inhibition by aspirin cannot reach to enough level in diabetes patient. Still, this [inaudible 00:16:57] hypothesis, very interesting hypothesis. Dr. Saito:              I think so, I think so. That review that proposed the same concept, their higher dose of aspirin as possibly effective for diabetic patient. Dr. Lam:               That's interesting. Are you planning any future studies Yoshi? Dr. Saito:              Yeah, maybe two times study. Dr. Goto:             But anyway, the event rate is currently very low than the old [inaudible 00:17:28]. So the sample size should be huge. Huge sample size is needed for the primary prevention setting to analyze the effect of aspirin, so the number needed to treat in the primary prevention setting is more than 1000. If diabetes patient, aspirin is resistant to aspirin so the number needed to treat is getting larger. So the sample size is getting larger and larger. That is not practical to perform that clinical trial. Dr. Lam:               That's a very good point that the contemporary trials like yours are really challenged by the low event rates because of improved preventive treatment across the board like high dose statins, like very, very low LDL targets, and so on. That's a good point. Actually, could I ask both of you gentlemen, and maybe Shinya you can start, can you let us know what is it like to perform such a large rigorous clinical trial in Japan? It must be a lot of effort. Could you give us an idea? Dr. Goto:             In Japan, medical care system is a little bit different from the U.S. Every patient covered by the homogeneous health care system so it means it is rather difficult to conduct a clinical trial. I appreciate the effort by Professor Saito, Yoshi, it is extremely difficult to conduct the study. Japan is relatively small island, patient stick to the clinic so the long term follow up with relatively low follow up can be expected. [inaudible 00:19:15] number of patients is a challenge, and Yoshi did succeed it. We can do that and due to the baseline therapy is quite homogenous, impact of the clinical care like this has very strong impact. Dr. Lam:               Exactly, and I share your congratulations once again to Yoshi for really tremendous effort, important results. Thank you so much Shinya for helping with this paper, and for really highlighting how really important it is. Did anyone have anything else to add? Dr. Saito:              Yes, I have one thinking, in respect to the Japanese clinical trials. I think the Japanese evidence, as derived from Japanese clinical studies is getting better and better in quality. Almost all Japanese clinical trials enrolled only Japanese patients, so the way the Japanese not so good at to organize the international clinical trial because of the, one is the language problem, and the other is funding problem. In Japanese funding agency, the AMED, that is similar to the NIH in United States, but AMED is not so strong as NIH so that they cannot give a bigger budget to the Japanese clinicians. That is another problem to organize a big clinical trial. The funding [inaudible 00:20:49] apprenticeship without holding investigators are very, very important to be better clinical situation in Japan, I think so. Dr. Lam:               Thank you for listening to Circulation on the Run, don't forget to tune in next week.