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In partnership with the Institute for Healthcare Improvement, this program is designed to bring clinical evidence into practice by connecting practitioners to authors of JAMA articles.
97 Episodes
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Interview with Justin B. Dimick, MD, MPH, author of Bariatric Surgery Complications Before vs After Implementation of a National Policy Restricting Coverage to Centers of Excellence. Summary Points:
Bariatric surgery has become much safer over the past decade, likely due to better techniques, training in advanced laparoscopy, and tighter credentialing of surgeons.
The CMS policy of restricting care to Centers of Excellence has not improved outcomes, but may have had the unintended consequence of reducing access to care.
Referring patients to Centers of Excellence for bariatric surgery will not lower the risk of adverse outcomes and decisions should be based on other factors, such as a surgeon’s training, experience, and outcomes.
Interview with Phillip M. Boiselle, MD, author of Computed Tomography Screening for Lung Cancer. Summary Points:
CT screening reduced lung cancer-specific mortality by 20% in a large randomized trial of a high-risk population.
CT is associated with a high false-positive rate, with associated risks and costs associated with follow-up CT and the potential for more invasive diagnostic procedures.
Physicians should consider discussing CT screening with their high-risk patients who meet criteria in published guidelines.
Interview with Daniel J. Buysse, MD, author of Insomnia. Summary Points:
Insomnia is a frequent comorbid condition that increases costs and worsens outcomes.
Insomnia is a chronic condition for which there are effective and widely available acute treatments (medications) and effective but hard-to-find long-term treatments (behavioral).
Need to consider other health professionals such as nurses, physician assistants, and behavioral health managers (smoking, obesity, diet, exercise, sleep/insomnia).
Interview with Daniel S. Chertow, MD, MPH, author of Bacterial Coinfection in Influenza: A Grand Rounds Review. Summary Points:
Influenza vaccine remains the best available tool for prevention of severe influenza illness commonly associated with bacterial coinfection.
Early empirical antiviral and antibiotic therapy should be administered to all individuals with suspected coinfection.
Vancomycin or linezolid should be administered in addition to standard therapy for community-acquired pneumonia to patients with severe or necrotizing pneumonia and/or evidence of sepsis.
Interview with Robert H. Shmerling, MD, author of Management of Gout: A 57-Year-Old Man With a History of Podagra, Hyperuricemia, and Mild Renal Insufficiency. Summary Points:
Risk factor modification: alcohol intake, excess weight, diet, medications (although overall impact on gout uncertain).
Acute gout can be treated with NSAIDs, colchicine, corticosteroids, or a combination of these.
Urate-lowering treatment to prevent attacks and tophi is appropriate for certain patients with gout. (In my opinion, allopurinol is the best initial choice to suppress uric acid.)
Urate-lowering treatment should suppress uric acid to 6.0 mg/dL or less; allopurinol should start no higher than 100 mg/d but titrate up based on uric acid levels; it is common to require more than 300 mg/d.
Concomitant prophylaxis (eg, low-dose colchicine, 0.6 mg/d) is appropriate for 6-9 months or longer.
Take home message: We now have new therapies and guidelines for the treatment of gout. Appropriate use of therapeutics for gout—both new and old—will provide optimal outcomes for the increasing number of patients with this common disease.
Interview with Laura N. Gitlin, PhD, author of Nonpharmacologic Management of Behavioral Symptoms in Dementia. Summary Points:
Attending to behavioral symptoms is part of comprehensive dementia care and requires ongoing long-term management.
Use 6 steps to systematically prevent, assess, manage, eliminate or reduce behavioral symptoms.
Use combination of nonpharmacologic approaches.
Keep trying—nonpharmacologic approaches are relatively adverse free.
Create a health professional team to offset time needed for provision of nonpharmacologic approaches.
Interview with Nancy A. Rigotti, MD, author of Strategies to Help a Smoker Who Is Struggling to Quit. Summary Points:
Treat tobacco use like the chronic disease that it is. Don't give up if your first few efforts do not succeed.
Medications and brief counseling are each effective, but combining the two is most effective.
Link your smokers to free national resources like the tobacco quit lines (1-800-QUIT-NOW). New noncombustible tobacco products are coming.
Interview with Robert W. Haley, MD, author of Controlling Urban Epidemics of West Nile Virus Infection. Summary Points:
Epidemics of West Nile neuroinvasive disease have become a serious medical and public health challenge that will be with us for the foreseeable future.
Ultra low-volume aerial spraying of urban areas, guided by surveillance of mosquito trap positivity and human cases, is necessary and cost-effective to prevent chronic neurologic disability and death.
Complete, accurate, and timely diagnosis of West Nile viral disease in an epidemic is vitally important to spare patients needless prolonged antimicrobial therapy and build support for public health control measures.
Interview with Philip Greenland, MD, author of Comparison of Novel Risk Markers for Improvement in Cardiovascular Risk Assessment in Intermediate-Risk Individuals. Summary Points:
In comparison with other competing biomarkers and risk factors, coronary artery calcium (CAC) is currently the most potent risk marker of subclinical coronary heart disease (CHD).
CAC was shown in several observational studies to improve the prediction of risk beyond traditional risk factors.
In this JAMA paper, CAC outperformed various competing risk assessment markers among asymptomatic people at intermediate risk for CHD. Whether CAC should be used in routine clinical practice, however, is still a matter of personal opinion or further research.
Interview with Melanie A. Thompson, MD, and Paul A. Volberding, MD, authors of Antiretroviral Treatment of Adult HIV Infection 2012 Recommendations of the International Antiviral Society-USA Panel. Summary Points: Antiretroviral treatment is recommended and should be offered to all persons with HIV, regardless of CD4 cell count. Particular attention should be paid to the design of an antiretroviral regimen for persons with concurrent conditions, such as viral hepatitis, opportunistic infections, and other medical diseases, because of the potential for drug interactions. Monitoring of entry into and retention in HIV care, adherence to antiretroviral therapy, and quality of care indicators are recommended and should be used to increase care engagement and quality.
Interview with Peter B. Bach, MD, MAPP, author of Benefits and Harms of CT Screening for Lung Cancer: A Systematic Review; and George T. O’Connor, MD, MS, author of Lung Cancer Screening, Radiation, Risks, Benefits, and Uncertainty. Summary Points:
Three randomized trials examined computed tomography (CT) screening for lung cancer’s effect on lung cancer mortality—one showed a benefit, the other 2 did not but were smaller studies.
CT screening does not appear to reduce mortality from causes other than lung cancer.
There are still a lot of uncertainties regarding the risks and how to mitigate them.
Interview with Mary A. Whooley, MD, author of Diagnosis and Treatment of Depression in Adults With Comorbid Medical Conditions: A 52-Year-Old Man With Depression. Summary Points:
Depression screening has no benefit unless it is combined with team-based management
Self-management strategies (behavioral activation and exercise) improve depression
"TEAMcare" can improve both depression and chronic medical conditions
Interview with Rita F. Redberg, MD, author of Healthy Men Should Not Take Statins; and Michael J. Blaha, MD, MPH, author of Statin Therapy for Healthy Men Identified as "Increased Risk". Dr Redberg's Summary Points: 1. Drugs given to asymptomatic persons should either help them to feel better or live longer. 2. Statins do not meet these criterion. 3. Lifestyle is cornerstone of primary prevention. Dr Blaha's Summary Points: 1. High-quality literature supports statins for reduction of first heart attack and stroke, in addition to a mild decrease in all-cause mortality over 3 to 5 years. 2. The key to efficient use of statins in primary prevention is risk stratification. 3. We must demand high-quality evidence for benefit and for harm in a potentially beneficial medication class such as statins. 4. Physicians should adhere to national guidelines to guide statin use in primary prevention.
Interview with James T. Pacala, MD, MS, author of Hearing Deficits in the Older Patient: "I Didn't Notice Anything". Summary Points: 1. Age-related hearing loss is extremely common and underrecognized by most health care providers. 2. There are many effective methods of detection of hearing loss that are easy and efficient. 3. Although the main stay of treatment is amplification, there remain many challenges to effective hearing aid use.
Interview with David S. Ludwig, MD, PhD, author of Weight Loss Strategies for Adolescents: A 14-Year-Old Struggling to Lose Weight. Summary Points: 1. Childhood obesity arises from a complex interplay of biology, behavior, and the environment. Consequently, successful treatment requires targeting multiple determinants of body weight. 2. Family-based treatment offers the most immediate and effective approach for childhood obesity, with benefits for all family members. 3. Ultimately, the solution to the obesity epidemic will require a comprehensive public health strategy to make the social environment healthier for children and adults.
Interview with Harold Sox, MD, author of New American Cancer Society Process for Creating Trustworthy Cancer Screening Guidelines. Summary Points: 1. Trustworthy guidelines require transparency about purpose, process, evidence, and rationale. 2. Trustworthy guidelines require a systematic review of the pertinent evidence. 3. Expertise in evaluating evidence and freedom from financial conflicts of interest are the main requirements for membership on a guidelines panel. If these are present, then clinical skills are important.
Interview with George A. Bray, MD, author of Effect of Dietary Protein Content on Weight Gain, Energy Expenditure, and Body Composition During Overeating: A Randomized Controlled Trial. Summary Points: 1. Excess calories are stored as fat, independent of protein. 2. Protein increases metabolic rate and lean body mass. 3. Adherence to a diet is more important than the macronutrient composition of that diet.
Interview with Daniel Leffler, MD, MS, author of Celiac Disease Diagnosis and Management: A 46-Year-Old Woman With Anemia. Summary points: 1. Celiac disease can present at any age with a wide variety of signs and symptoms and delay in diagnosis is common. 2. Testing for celiac disease with IgA tissue transglutaminase is accurate and cost-effective. 3. The only treatment for celiac disease is the gluten-free diet, but this is very burdensome and requires ongoing education and support.
Interview with Steven C. Zweig, MD, MSPH, author of The Physician's Role in Patients' Nursing Home Care. Summary Points: 1. Prevalent, fragile population, cared for until the end of life. 2. Care must be interdisciplinary (Facility, staff, physicians; Residents, family members). 3. Understand and anticipate natural history of aging and decline in long-term care, including planning, assessment, continuing care, acute care, and end-of-life care.
Interview with Michael Paasche-Orlow, MD, MA, MPH, author of Caring for Patients With Limited Health Literacy: A 76-Year-Old Man With Multiple Medical Problems. Summary Points: 1. Massively increase patient education. 2. Systematically reduce unneeded complexity and variability. 3. Universal precautions (not screening), flip the default, and confirm comprehension (T2G).
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