Clinical Conversations

What’s causing this resurgence, and what’s to be done? Pejman Rohani talks about his Science Translational Medicine study that used “gold standard” historical data to examine possible causes.

He and his colleagues conclude that, as with mumps, slowly waning vaccine protection is at play. However, they identify the “core transmission group” as schoolchildren, who have a greater frequency of contacts. Adults, they find, have “at most a minor role.”

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Mumps outbreaks keep happening, even among vaccinated groups. Why?

Our guest, Joseph Lewnard, and his coauthor, Yonstan Grad, probed studies of mumps vaccine efficacy carried out over five decades. They show that the fault, dear clinician, is not in our vaccines or new viral strains, but in ourselves. Our bodies slowly lose their immune response after vaccination, and about 25 years after the last vaccine dose, it’s gone.

Listen in.

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Science Translational Medicine study

CDC recommends a third dose of MMR vaccine in an outbreak

There simply isn’t enough evidence to sustain its continued use in asymptomatic men, argues our guest. Dr. Jason Profetto, senior author on an Annals of Family Medicine meta-analysis.

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Annals of Family Medicine abstract

Physician’s First Watch coverage

An analysis of the states’ integration of midwifery into their healthcare systems concludes that better integration led to better outcomes for mothers and babies.

We discuss this with Dr. Saraswathi Vedam, the study’s first author.

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University of British Columbia’s Birth Place Lab

PLoS One article

First Watch coverage of the Lancet series on midwifery

The EPCAT II trial examined whether aspirin and rivaroxaban were clinically equivalent in the extended prophylaxis of venous thromboembolism after hip or knee replacement. They proved “comparably effective and safe,” according to our guest, Dr. David Anderson, the study’s first author. An editorial in the New England Journal of Medicine, where the study appeared in February, calls the results practice-changing. One thing was sure from the outset — aspirin is cheaper than rivaroxaban by orders of magnitude.

A note to listeners: Dr. Anderson and I conducted the interview over several sessions, so the first-half audio sounds a bit rougher than the second. Your speakers don’t suddenly get better — my equipment does!

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NEJM report

NEJM editorial

Journal Watch General Medicine summary

A recent paper in JAMA Internal Medicine sought to examine what happens after breast cancer screening with magnetic resonance imaging. It reported that core and surgical biopsy rates doubled, compared with mammography, in women with a personal history of breast cancer; they rose fivefold among women with no personal breast cancer histories.

Dr. Diana Buist, the study’s principal author, helps sort out the implications of this study, done on some 2 million screenings.

Running time: 18 minutes

JAMA Internal Medicine paper

USPSTF guidelines on breast cancer screening for normal-risk women

American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography

National Comprehensive Cancer Network clinical practice guidelines on breast cancer

Timothy Hoff thinks clinicians “must finally recognize that they are indeed ‘workers’ whose ability to control their daily fates has been reduced greatly.” He worries about the continuing erosion of the doctor-patient relationship, and he wonders why the profession is so reluctant to view its members as “put-upon workers struggling to gain favorable conditions for their work within corporatized health care settings.”

We talked with Prof. Hoff about his just-published book: “Next in Line: Lowered expectations in the age of retail- and value-based health.”

To the barricades!

“Next in Line” (link to Oxford University Press site)

The non-vitamin-K oral anticoagulants (known familiarly as NOACs or DOACs) share metabolic pathways with other drugs, which can potentiate NOACs’ anticoagulant actions dangerously. Dr. Shang-Hung Chang and his group studied Taiwan’s national health insurance database, which records data on virtually all that nation’s citizens, to measure the actual risks of some of these drug – drug interactions. Their findings were published earlier this month in JAMA.

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JAMA article (abstract)

Physician’s First Watch coverage

Pregnant women with type 1 diabetes can realize more than better control with continuous glucose monitoring: their babies are less likely to be large for gestational age and less likely to spend time in neonatal ICUs. Dr. Denice Feig, who authored a recent international study in The Lancet, talks about her findings and makes recommendations for the future.

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Lancet study

Physician’s First Watch summary

There was an excellent commentary accompanying a recent JAMA Internal Medicine meta-analysis: “The Ideal Blood Pressure Target for Patients with Chronic Kidney Disease — Searching for the Sweet Spot” by Csaba Kovesdy. He offers a nice perspective on the problem and kindly agreed to talk with us.

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