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August 16th, 2019

Podcast 229: Simplifying perioperative anticoagulation in AF

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Patients with atrial fibrillation who undergo surgical procedures need special attention because their anticoagulant medications, if not adjusted, increase their risk for bleeding. Those on direct-acting oral anticoagulants — or “DOACs” — face special problems because assays for the amount of drug on-board before surgery are not routinely available.

Dr. James Douketis and international colleagues have a simpler approach in their PAUSE study. On the basis of the known pharmacokinetics of DOACs, they dispense with coagulation testing and heparin bridging. Their approach involves assessing the likelihood of the procedure to cause bleeding. For low-risk procedures, DOACs are suspended a day before and resumed a day after; for riskier procedures, like resections, it’s two days before and two after.

The drugs under study were apixaban, dabigatran, and rivaroxaban.

We discuss the PAUSE results with Dr. Douketis.

LINKS:

JAMA Internal Medicine paper on PAUSE study

Physician’s First Watch summary (with links to other resources)

August 8th, 2019

Podcast 228: Hematuria — should the workup include imaging?

(1 votes, average: 3.00 out of 5)

Matthew Nielsen and colleagues found almost 80 diagnostic algorithms for working up a finding of hematuria. From these, they chose five representative approaches, ranging from those based on the patients’ risk factors to more aggressive ones that stress CT imaging for all.

Using a 100,000-patient simulated cohort, Nielsen’s group found that more intensive imaging found more cancers than the other approaches. However, radiation-induced cancers from CT wiped out that advantage.

Join us as Dr. Nielsen walks through his findings and their clinical implications. The work appeared in JAMA Internal Medicine.

Links:

JAMA Internal Medicine article

NEJM Journal Watch General Medicine summary of ACP guidance on evaluating hematuria (from 2016)

American Urological Association guideline (from 2012)

 

August 2nd, 2019

Podcast 227: Chronic kidney disease and anticoagulants

(1 votes, average: 4.00 out of 5)

Chronic kidney disease, being a “prothrombic state,” would seem to warrant use of anticoagulants, yet they aren’t often used — why? The problem seems to be a lack of data with which to evaluate their effectiveness and possible harms. Big drug trials seem to avoid recruiting these patients, especially those in the later stages of CKD, where, for example, the risk for thromboembolism is two- to three-fold greater than in patients with normal kidney function.

We talk with Dr. Sunil Badve, senior author of a meta-analysis in a recent Annals of Internal Medicine. His findings? Non-vitamin K oral anticoagulants (or “NOACs”) seem better suited for those with early-stage disease than vitamin K antagonists like warfarin. In later-stage CKD, there just isn’t enough data available yet, and so the choice of therapy — if any — must weigh benefits against harms carefully.

Links:

Annals of Internal Medicine meta-analysis

Physician’s First Watch coverage

June 11th, 2019

Podcast 226: What we need to talk about when we talk about health

(3 votes, average: 3.00 out of 5)

Length: 18 minutes

Sandro Galea, dean of Boston University’s School of Public Health, has written a new book. It’s called “Well: What we need to talk about when we talk about health,” and it’s the centerpiece of our discussion.

Dr. Galea, who trained as an emergency physician, believes that health is a public good and thus worthy of public investment in the things that will promote health in the future, like public education, breathable air, drinkable water, and the like.

Listen in.

The book is available through Amazon or your local bookseller. It’s published by Oxford University Press.

November 28th, 2018

Podcast 225: Managing diabetes in primary care — are there quality differences among NPs, PAs, and MDs?

(6 votes, average: 3.83 out of 5)

Does the diabetes care afforded by NPs and PAs match that of MDs? According to a careful analysis among Veterans Affairs patients there are no clinical differences in intermediate outcomes — hemoglobin A1c, systolic pressure, or LDL cholesterol.

The principal and senior authors of that analysis are our guests this time.

Links:

August 23rd, 2018

Podcast 224: What’s a “preprint server,” and how might it change how we think about journals?

(5 votes, average: 5.00 out of 5)

Rohan Khera wrote an editorial in The BMJ to accompany his own paper on guidelines for hypertension treatment. In it, he wrote, not about his research, but about the way biomedical articles are published now, and how preprint servers could change that. (In essence, pre-print servers are online repositories of rough drafts of research available for all to see; articles on such servers have not been subjected to peer review.)

Khera’s research article, it should be noted, originally appeared months earlier in draft form on BioRxiv, a biomedical preprint server.

Khera argues that the “official” journals are too slow. He fears their slowness. for instance, can prevent important data from reaching policymakers when it’s most needed — while they are making decisions based on new research languishing in the standard publication process.

Khera’s BMJ commentary

Khera et al.’s preprint on BioRxiv

Khera et al.’s resarch article as published in The BMJ

Conversation with Harlan Krumholz (from 2016): “Rethinking what medical journals do”

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