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March 10th, 2020

Podcast 256 — Anthony Fauci: Talking with patients about COVID-19

(125 votes, average: 3.56 out of 5)

We have Dr. Anthony Fauci of NIAID to talk with us about COVID-19, the disease caused by the 2019 novel coronavirus (also known as SARS-CoV-2). He’s full of sound advice in the midst of a rapidly changing epidemic.

We wanted to know, How do you talk with patients about this rapidly spreading infection? How do you keep informed about it?

Listen in.

Link:

The new federal website

Running time: 13 minutes

TRANSCRIPT OF THE INTERVIEW

Joe Elia: 

This is Joe Elia.

 

If you’re like the clinician I heard from last week who said she’s spending half her time counseling patients about COVID-19, you’re probably wondering how best to discuss the problem with your patients.

 

This time my co-host, Dr Ali Raja, and I are talking with Dr Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases about how clinicians might approach these conversations and about how both parties — clinician and patient — can best inform themselves about the developing details of this widespread illness.

 

Dr Raja is helping to direct the Mass. General Hospital’s emergency department’s response. He’s Executive Vice Chairman of the Department of Emergency Medicine and he edits the NEJM Journal Watch Emergency Medicine newsletter.

 

Dr Fauci has directed NIAID for some 25 years, arriving in the early years of the HIV/AIDS epidemic. He has advised six US Presidents on health issues. Most recently we’ve all noticed that he’s become the principal clinical voice in this country’s response to the threat of COVID-19 as a member of the White House Coronavirus Task Force.

 

Dr Anthony Fauci:

Well, first of all I’ve directed the Institute for 36 years, not 25 years.

 

Joe Elia:

I’m sorry, Dr Fauci.

 

Dr Anthony Fauci:

You’re making me younger than I am!

 

Joe Elia:

Time flies when you’re having fun, right?

 

Well, so welcome to Clinical Conversations, and we’ll try to get other facts right as we talk to you! We’re going to keep this simple and frontline-clinical to respect your time and preserve your voice. I’ll have Dr Raja ask the first question.

 

Dr Ali Raja:

Thanks, Joe. Welcome, Dr Fauci.

 

Dr Anthony Fauci:

Good to be with you.

 

Dr Ali Raja:

You can imagine that we’ve been getting a lot of patients coming into emergency departments around the country, I’ve seen them here at MGH, with questions and with concerns. Honestly, I’ve struggled with the best way to advise them, so let me ask you. Beyond good hand hygiene and common sense regarding reducing transmission, what can we tell our patients about COVID-19 both to make them aware of the potential risks but also to hopefully calm them and help with the sense of panic that we’re feeling?

 

Dr Anthony Fauci:

Yeah. I mean, obviously a pivotal and great question that every one of us are facing.

 

So I think to give them the broad picture without unnecessarily sugar-coating because we’re in a really serious situation here.

 

But for the individual patient I try to explain that they should not take upon themselves the burden of the broader global health issue. So if you look at the situation of what it means to get infected, in the United States as a country in general the risk of getting infected is clearly very low.

 

However, the situation is changing, it’s evolving, and the difference of sitting in a place where there are either no cases or two or three easily documented cases. Like a travel case: Someone comes in from Iran to New York, they nail it, they isolate them, it isn’t in the community yet. You have a cluster there.

 

But for somebody who walks into an ER in an area where there isn’t community spread, the risk of getting infected is low. However, if you do get infected we need to look at the data that we have now and the data predominantly are from China, South Korea, northern Italy, and Japan, and that is about 80 percent of the people who get infected do well. I mean, they’re not asymptomatic, they have a flu-like illness but they recover spontaneously without any specific medical intervention, so to give them a feel.

 

However if you are an individual who has an underlying condition of which you’re all familiar with — chronic obstructive pulmonary disease, cardiovascular disease, congestive failure, diabetes, anything that could compromise your immune system — if you get infected then you have a much higher chance of having a complication, and then if you look at the serious disease and death it’s totally weighted to that group with the occasional one-off outlier that we even see with flu: A 35-year-old person who’s perfectly well gets the flu and then gets really sick and might die. That can happen, but different from flu, children and young people do really, really well with this.

 

So you give them the broad picture, that should take like two minutes in the office to tell them that. Then you tell them what do you need to do. Right now in places like Seattle, LA, New York, and Florida there’s clear community spread so what you need to do is start already what we call social distancing which some people don’t understand what that means. It just means separating yourself as best you can. No crowds, don’t get on crowded planes if you’re a senior citizen, particularly with an underlying condition. Don’t get on a cruise ship for sure. Wash your hands as much as you possibly can, and if you have a person in your own home who is immunocompromised or falls into that compromised group, you almost have to act like you yourself are infected.

 

So if you’re a 35-year-old person who feels healthy and you have someone in your home that’s on cancer chemotherapy, you’ve got to protect them. You’ve got to physically distance yourself from them. Now that’s now in Massachusetts.

 

If you happen to be in Seattle you’ve got to do more than that. You yourself have to do a lot of social distancing because when you have community spread then you just don’t know the penetration in the community unless you do a massive screening in the community, and that’s where we really need to catch up because what I’d like to see is just flooding the system with testing to see what percentage of people who come into any emergency room actually have COVID-19. If that’s 0.1 percent, okay. If that’s four percent, time out, we really have a problem.

 

Anyway, I was a little bit more long-winded than my usual answer but…

 

Dr Ali Raja:

That was exactly what we needed. Thank you.

 

Joe Elia:

Thank you, and Ali, what’s the situation at Mass General?

 

Dr Ali Raja:

Well, Joe, as an example let me tell you about the kinds of things that we’ve done in anticipation of a more widespread impact of this virus. As Dr Fauci mentioned we aren’t Seattle yet but we’ve already converted our ambulance bay to a large sealed-off treatment area that allows us to screen and test for patients separate from the rest of the emergency department when they meet the current CDC criteria.

 

And I want to emphasize that last part because the target seems to constantly be evolving and changing and so in addition we’re having daily meetings with all of our clinicians and our clinical leadership but also our supply chain leaders, our hospital administrators to make sure that the hospital keeps transforming based on the information that seems to be changing every day.

 

Dr Anthony Fauci:

That’s a really good point. This is not a static situation. It literally changes every day and that’s so difficult to do when you’re trying to put into place the kind of things that Ali just mentioned. You got to, as you say, meet every day and figure, Do we have to turn the knob one way or the other? That’s really important message.

 

Joe Elia:

I’d like to ask you, Dr Fauci, what do you consider the best sources of information for clinicians and the public who want to keep abreast of that changing information? Is it the CDC site or is it MMWR? What would you recommend?

 

Dr Anthony Fauci:

You know, the CDC has put up a site, the Federal government, it’s an all-of-government site. It’s called Coronavirus.gov. They just put it up. I mean, we said at the press conference yesterday “Just dial coronavirus.gov,” and I did and it wasn’t where I needed it to be. But it should be there today. The other thing is that what we’re putting up on the website is something that we literally put together yesterday and it is what to do at home, what to do at the workplace, what to do in the hospital, what to do here, and really simple talk that not only physicians can benefit from but the general public.

 

So I would do CDC.gov and coronavirus.gov.

 

Dr Ali Raja: 

Perfect. I’ll go there today actually. Dr Fauci, what about our listeners? The public isn’t typically going to listen to our podcast but a lot of clinicians do. What do the clinicians themselves do? What should they be doing given the conflicting ongoing need to be able to continue to screen and treat patients who are potentially affected, but also avoiding getting ill themselves? We know the basics of wearing the masks and the gowns, but what else can we be doing or what should we be doing as a system to protect our clinicians?

 

Dr Anthony Fauci:

Yeah. I mean, obviously that is so critical because if you look at what happened in China, the healthcare providers, I mean, there was like 1700 of them in just in the city of Wuhan who got infected. I would do as strict precautions as you possibly can. I would clearly wear an N95 mask, absolutely. I would wash your hands until it starts getting chaffed. I mean, we do that anyway with universal precautions but I would clearly do that.

 

The other thing, if you start and you will, guys. You’re going to start seeing cases come in. I mean, it’s inevitable.

 

Yeah, I would just…when people call in, and I know you’re doing that, you got to tell them and you said you have a system that’s segregated, that if you feel sick don’t just come into the emergency room. Stay at home for now and if you’re going to come in, figure out a way that they don’t come in and essentially infect five other people when they come in. That I think the clinicians need to know.

 

First instinct is that if this person has it I want to take care of them. You can take care of them but you got to be careful about essentially making the matter worse.

 

Joe Elia:

Dr Fauci, I wanted to ask you, what is the one thing you hope that people listening to this podcast will do differently in response to COVID-19?

 

Dr Anthony Fauci:

You know, it’s a binary thing. I want them not to panic because panic gets people to do unreasonable things that are even counterproductive to what you’re trying to do from a public health standpoint. You might overwhelm systems when you don’t need to overwhelm systems. But on the other hand without panicking and without making it dominate your life, pay attention to the fact that you have to act differently like you’ve never acted before. You’ve really got to be socially distant.

 

You know, it’s very interesting that my deputy was one of the two Americans who went to China as part of the WHO umbrella group that visited and in China now, they got hit badly, they had a few missteps in the beginning but they’re getting it right now. I mean, they’re really being super, super careful. They don’t allow anyone to eat at a common  table. They have these little tables that are separated from each other in the hospital and other places where people don’t mingle. I mean, we’re all social beings but for the next few months, and I hope it does go down, it might not, but I hope it does the way flu does, we just got to hunker down. It’s part of what we need to do, we need to hunker down.

 

Joe Elia:

All right. I want to thank you, Dr Fauci, for talking with us today.

 

Dr Anthony Fauci:

It’s my pleasure.

 

Joe Elia:

Best of luck to you and to you, Ali, in the coming months. Thank you again.

 

Dr Anthony Fauci:

Thank you both. Thank you, Ali. It’s a pleasure to meet you.

 

Dr Ali Raja:

You as well. Thank you.

 

Dr Anthony Fauci:

Take care.

 

Joe Elia:

That was our 256th episode. The whole collection is searchable and available free at podcasts.jwatch.org. Clinical Conversations is a production of the NEJM Group and we come to you from NEJM Journal Watch. The Executive Producer is Kristin Kelley. I’m Joe Elia.

 

Dr Ali Raja:

And I’m Ali Raja. Thanks for listening.

March 5th, 2020

Podcast 255: Salt talks — transcript included

(4 votes, average: 3.00 out of 5)

Here we have an interview with Prof. Feng He, whose English is much better than my Mandarin. Thus, I’ve attached a transcript to make her ideas on salt intake (no level is too low) and blood pressure (there’s a dose-response relation with salt) more immediately available than it might be to your ears alone.

She’s coauthor of an article in The BMJ — a meta-analysis — that finds the effect of salt is greater with age, and in non-white populations and those with hypertension.

Links to articles mentioned and apps:

Running time: 28 minutes

Here is a transcript of the interview:

TRANSCRIPT OF INTERVIEW WITH PROF. FENG HE WHO HAS REVIEWED AND CORRECTED IT

Joe Elia:
Salt and sodium intake have challenged medical researchers for generations. What seems indisputable is that too much salt is not good, especially in hypertension. After that things get fuzzier. National advice on restricting salt intake has been challenged by findings that restricting salt too much can increase cardiovascular risk.

Professor Feng He and her colleagues looked at the question of whether existing studies showed a relation between reductions in dietary sodium and changes in blood pressure. They performed a meta analysis of 133 studies comprising some 12 thousand 200 participants. Those studies all randomly allocated participants to either reduced sodium intake or usual (and thus higher) intake. All studies collected 24-hour urine sodium data to estimate those intakes. In short, they found a dose – response relationship between intake and blood pressure change.

Professor He works at the Wolfson Institute of Preventive Medicine at Barts and the London School of Medicine and Dentistry, Queen Mary University of London. Welcome to Clinical Conversations, Dr. He.

Dr Feng He:
Thank you. Thank you for having me.

Joe Elia:
You have been researching salt for about 25 years. What have you observed about the research over that time? Have you changed your mind about the effect of dietary salt and health and blood pressure?

Dr Feng He:
No, I haven’t changed my mind, because when you look at salt reduction as a public health strategy, you need to look at the totality of evidence. You need to look at all different types of studies, including epidemiological studies, population-based intervention studies, randomized trials in humans, animal studies, and also physiological studies.

So all of these different types of studies have consistently shown that a high salt intake is a major cause of raised blood pressure. Salt intake is also an important determinant of the increase in blood pressure with age. I remember when I was in medical school, we were taught that systolic blood pressure increases with age — that this is a normal physiological phenomenon. But later scientific evidence has clearly shown that this is not normal, and that high salt intake is an important contributor for the increase in blood pressure with age.

If you look at the societies now, you know, there are still some societies isolated to tribes. They don’t have added salt in their diet, and that’s like our human ancestors, And their blood pressure, their average blood pressure for the adult population is only 90/60 mm Hg, and their blood pressures do not increase with age and these populations do not have cardiovascular disease at all. You may say, “No, people in isolated tribes die at a much younger age.” However, if you compare those isolated tribes with Western populations of the same age group, in Western societies so many people suffer or die from cardiovascular disease.

Joe Elia:
Yeah. The fact that the research is ongoing tells us that not everyone believes that the results are final yet. Would you agree with that?

Dr Feng He:
No. Actually you know, you never get a final result because you know what? For any dietary factors, it is extremely difficult to do randomized outcome trials. Remember, for salt reduction you have to randomize many thousand individuals to the high-salt or the low-salt diet and keep these two groups for many, many years to see whether there’s a difference in cardiovascular outcome.

The problem with this is, firstly, there’s overwhelming evidence that shows that a high salt intake is harmful to human health. It’s unethical to put a group of people on a high-salt diet for so many years.

Secondly, you know, on the lower-salt group in the current food environment, it is extremely difficult for individuals to keep to the lower-salt diet for many, many years. That’s almost impossible in the current food environment.

And thirdly, many countries have started salt reduction initiatives — governments and NGOs have programs as do health professionals. Even in the media — in the control group if you want them to be on the high-salt diet, they’ll receive all these messages from the media — from the radio, from television, from newspapers. They [high-salt controls] will lower their salt intake, too. So in the end you wouldn’t see a difference in salt intake between the two groups and then there’s a severe contamination between the two groups.

So it’s difficult to do such outcome trials you know, to keep two groups on the low and the high salt there for many, many years.

Joe Elia:
I see. Is it possible to lower salt intake too much?

Dr Feng He:
No, if you look at those isolated tribes, they don’t have added salt to their diet. You know, there’s lots of food, and some of the food naturally already has sufficient salt, like meat. Our ancestors, they did not have added salt, but they lived healthily. Now in the isolated tribes, they are still living in the lifestyle of hunter-gatherers. They don’t have added salt. Their salt intake as measured by 24-hour urinary sodium excretion is less than 1 g a day. It’s much lower. You know, they live perfectly well. They don’t have cardiovascular disease.

So, you know, in our current food environment in Western societies there’s no way you could reduce salt intake to such a level. Currently in most countries the average salt intake is about 10 g per day and the WHO recommended level is 5 g per day. And for the US it’s 6 g per day and for the UK it’s also 6 g per day for the general population.

However, for the US, in almost half the population, the target actually is much lower. It’s 4 g per day for individuals with high blood pressure, people of African origin, and people with kidney disease, because they are at increased risk. So their target should be even lower — to 4 g per day.

Joe Elia:
Well, what prompted you and your colleagues to undertake this meta-analysis?

Dr Feng He:
This actually is an updated meta-analysis. I don’t know whether you know, we have published a meta analysis in 2013 in the same journal, The BMJ. At that time what we looked at was a modest reduction in salt intake and over a longer duration as the current public health accommodation. For example, from 10 g per day to 5 g per day to see whether that had significant effects on blood pressure. What we showed was that a modest reduction in salt intake for a longer term, like for a duration over a month or longer, there’s a significant effect on blood pressure in both hypertensives and normotensives.

So for the new meta-analysis, not only did we update it to include many more trials but also there’s a focus on the dose-response relationship with salt reduction and blood pressure. And we also looked at duration, whether the duration [of reduction] has any effect on the effect of the salt on blood pressure.

So this time the inclusion criteria were different. We basically included almost all of the salt reduction trials with 24-hour urinary sodium measurement. So with these many studies we have shown a clear dose-response relationship; so the greater the reduction in salt intake, the greater the fall in blood pressure.

The current public health recommendation is from the current level of approximately 10 g per day to the WHO-recommended level of 5 g per day. That will have a significant effect on lowering blood pressure. However, if you lower salt intake further, down to 3 to 4 g per day, the effects on blood pressure would be bigger. So there’s a clear dose-response relationship: the greater the reduction in salt intake, the greater the fall in blood pressure.

Joe Elia:
So you found that lowering salt intake is good for blood pressure, even among people without hypertension. But you were careful to limit your findings to blood pressure and not cardiovascular disease or other things, and…

Dr Feng He:
This is very good question. Because as I mentioned earlier, it’s extremely difficult to do a randomized trial for cardiovascular outcomes. Hardly any trials have looked at the longer-term salt reduction on cardiovascular outcome. And having said that, I don’t know if you have seen our previous meta-analysis published in the Lancet. Basically because there’s an insufficient number of studies looking at long-term salt reduction on cardiovascular outcome, what we looked at in that meta-analysis was the trials whose aim was to look at the blood pressure.

However after the trials completed, the researchers followed this population up for many years after the trial, so even that type of study you know, wasn’t exactly a long-term outcome trial;  but still, that type of study has indicated that a reduction in salt intake has a significant effect on reducing cardiovascular events.

Joe Elia:
But the question that you asked was a simpler one and in addition to lowering blood pressure across the board, you found that studies that were of a short duration, for instance two weeks or less, didn’t show the effect as much as those studies that were longer-term. Is that right?

Dr Feng He:
That’s right. That’s right. Basically these studies show that the dose-response relationship is much stronger in the longer-term trials compared to short-term trials. So it’s likely that the shorter-term studies have underestimated the impact of salt reduction. The problem with looking at the duration and looking at the effect of duration on the effect of salt reduction is quite difficult, because at the moment not many longer-term salt-reduction trials, only a few trials have had a duration lasting six months or longer.

The problem with this type of trial is, initially, people achieve their reduction of salt intake, but with time you know, with the current food environment it’s impossible for individuals to keep the lower-salt diet for long term. So by the end of, say, a few years their salt level has already gone back to the higher level, so that’s why longer-term studies cannot see a greater effect. Because over the longer term they have not achieved a greater reduction of salt intake.

So if you really want to look at the long-term effect, the duration, the effect of duration on blood pressure, we should have longer-term trials, with the individuals kept on the low-salt diets throughout with multiple measurements of blood pressure throughout. The only study that can show this is the DASH Sodium study. I do not know whether you have heard of the DASH Sodium study. In this DASH-Na study the compliance is perfect because it’s a feeding study. All of the food and the drinks are provided to the participants. So the individual can keep the lower salt diet over the whole study duration. That study has shown that, with a longer duration the effect of salt reduction on blood pressure is bigger, compared to short-term study.

A footnote: Dr. He wanted to add this observation after her comments on DASH: “Countries that have achieved a reduction in salt intake for several years, for example, Finland and the UK, have demonstrated a much greater impact of salt reduction on population blood pressure”.

Joe Elia:
The effects seemed especially stronger in older people, non-white populations, and those with higher baseline systolic pressures.

Dr Feng He:
That’s right.

Joe Elia:
Okay. And so I guess that’s the population it would seem that would have been exposed, especially older people, to this kind of food environment as you describe it, that is going to have loaded their bodies up with salt over many years, isn’t it.

Dr Feng He:
That’s one of the reasons but there are other reasons. In our human body we have these hormonal systems like the renin-angiotensin system, and this system is actually maintaining our blood pressure. And because for individuals with older age and people of African origin and also people with high blood pressure, their renin-angiotensin system is suppressed. And so usually, like in young people, if you reduce your salt intake, the renin-angiotensin system would react and then there’s an increase in plasma renin activity and increase in angiotensin II.

This is like a compensatory mechanism to maintain our blood pressure. So for elderly and for people of African origin and also for those with high blood pressure, this system is not as active as in young people or compared to their counterpart in the white population or people with normal blood pressure. That’s one of the mechanisms for those subgroups to have a greater fall in blood pressure for a given reduction in salt intake.

Joe Elia:
What do you think these findings mean for people who are skeptical about over-restricting salt intake? There have been some researchers in Europe — I know of one group — that have data saying that over-restriction of sodium leads to greater cardiovascular risk.

Dr Feng He:
Yes, I’m fully aware of these publications. We have published several papers and there’s lots of debate about this. The problem with their studies is that there are severe methodological problems. For example, their study measured salt intake using spot urine. Spot urine measured sodium concentration. For example, if I just have two glasses of water now, and two hours later I collect spot urine. If you measure my sodium concentration in that spot urine, it’s much lower because it’s diluted.

And also this spot urine, they converted spot urine sodium concentration to 24-hour urine sodium to estimate individuals’ daily salt intake.

Joe Elia:
I see.

Dr Feng He:
They used a formula to convert this spot urine sodium to 24-hour urine sodium. This formula included age, gender, sex, height, weight. We all know age is an important determinant of any health outcome and death, and that age is also associated with salt intake. And also the other factors — gender and body weight and a 24-hour urine creatinine — all of these factors are important confounding factors because they both related to salt intake, and also related to health outcome.

So in this study you know, they can’t control such confounding factors.

Joe Elia:
I see. Okay.

Dr Feng He:
So there’s a lot of methodological [errors]. We call it measurement errors. Using spot urine is one of the contributing factors for the J-shaped findings. We published a paper in the International Journal of Epidemiology and another one in Hypertension, and clearly showed that this formula — the variables like age and gender, height and weight, the creatinine concentration — they all are important contributors to the J-shaped findings.

That’s the only one of the factors. Another factor in lots of cohort studies is that they included people who are not well, who are sick. And this is called “reverse causation,” because we know that if you are not well you can’t eat, and then you have lower salt intake. And then because you’re not well, you have a chronic disease, you’re more likely to die, so the lower salt intake in these individuals is the consequence of their underlying disease and it’s [lower salt intake] not the cause. So there are lots of problems with the J-shaped findings. And so you see our recent paper [which] clearly shows that these different factors have contributed to the J-shaped findings.

If you use accurate measurements of salt consumption like we did, we analyzed the Trials of Hypertension and Prevention [TOHP] follow-up data. Actually that study was done in the US, and we collaborated with Professor Nancy Cook at Harvard University [Brigham and Women’s Hospital]. In the TOHP study, all the participants had multiple nonconsecutive 24-hour urine measurements and measured their salt intake, and so if you look at it, this salt intake, you can see there’s a clear linear association. So the lower the salt intake, the lower the risk of death, down to a salt level of actually 3 g per day. There’s no J-shaped or U-shaped relationship.

Joe Elia:
There is none. Okay. What do you hope will happen as a result of your continuing work on this and your current published analysis?

Dr Feng He:
I hope definitely there’s a clear message that salt reduction is extremely beneficial to the whole population, not only in those with high blood pressure but also in individuals with blood pressure in the normal range. So firstly, the general public need to be more salt-aware and also reduce their salt intake. And for the clinicians, they need to give their patients appropriate advice on how to reduce their salt intake, because in our clinic, sometimes the patient will say “Oh, my salt intake must be low because I never use salt in my cooking or at the table.”

But when we measure it, you know that salt intake is extremely high. The patients, they did not know that the food they usually eat — bread, breakfast cereal — are really high in salt. So in most of the Western countries like the US, UK, and in many other developed countries, about 80 percent of salt in our diet is added to our food by the food industry.

So for the food industry, they needed to make a gradual and sustained reduction in the amount of salt they add to all of their products. And the UK has been very successful in reducing the population salt intake. In 2000, 2003 we [the UK] started a salt reduction program in collaboration with the Food Standards Agency and also our group Action on Salt. What we did is to set incrementally lower salt targets for over 85 categories of food.

And the principle is a small reduction — a 10 to 20 percent reduction — and then you repeat it at two- to three-year intervals. And if you do it gradually, you know, small reductions, the general public wouldn’t notice any difference in their taste. And they can continue to buy the food that they usually buy and their salt intake will come down. The UK salt-reduction program has been really successful. From 2003 to 2011 salt intake in the population was reduced by 15%, from 9.5 g per day in 2003 to 8.1 g per day in 2011.

So this you know, 15% reduction in population salt intake has led to a significant reduction in population [systolic] blood pressure by 2.7 mm Hg, and this was associated with a significant reduction in population mortality from stroke and ischemic heart disease.

Joe Elia:
Oh. I think we should all be reading labels more carefully when we buy food.

Dr Feng He:
Definitely. For individuals in developed countries it’s important that when we do shopping, we choose the lower salt option, and actually now there’s an app available. You can use this app and scan the bar code and then it will give you the lower salt option and you know, there is a similar product that tells which ranks high in salt, which ranks low in salt.

Joe Elia:
What is the name of that app?

Dr Feng He:
It’s [Salt Switch]. Actually there’s a more comprehensive one, it’s called Food Switch.

Joe Elia:
Just a footnote here, Dr He contacted me after our interview and wanted to be clear that she had misspoken about the name of one of the apps. They are Salt Switch and Food Switch and I’ve included links to both on the website, podcasts.jwatch.org.

Dr Feng He:
And then in the UK, Australia, and in China, and in India, there’s an app, freely available for download and when you go shopping you just scan the bar code and it will give you the “traffic light” labelling. It tells you which one is healthier, and it gives you alternatives to buy.

Joe Elia:
Well, I want to thank you very much for talking with me today, Dr He.

Dr Feng He:
Thank you. Thank you very much. It’s so good to talk to you.

Joe Elia:
That was our 255th episode. All of them are available free at podcasts.jwatch.org. We come to you from NEJM Journal Watch and the NEJM group. The executive producer is Kristin Kelley, and I’m Joe Elia. Thank you for listening.
Page 4

February 27th, 2020

Podcast 254: Old malpractice liability strategies need rethinking

(1 votes, average: 5.00 out of 5)

JAMA recently published a review of some 40 papers examining the relation between malpractice liability strategies — tort reform, increased insurance premiums, etc. — and the quality of care. Apparently the efforts had no discernible effect on mortality rates, length of hospital stays, and the like.

An editorial accompanying the paper sketches out a vision of where future efforts should lead, especially given the shift in U.S. medicine from private to institutional practice.

The coauthor of that editorial — surgeon and law professor William Sage — is our guest.

Links:

Malpractice liability and health care quality article in JAMA

Sage and Underhill’s editorial in JAMA

Running time: 17 minutes

February 21st, 2020

Podcast 253: Is a single-dose HPV vaccination effective?

(1 votes, average: 5.00 out of 5)

With human papillomavirus vaccine in short supply around, moving from a three- or two-dose regimen to one dose would immediately double or treble supplies, cut costs, and simplify logistics.

A careful study in Cancer by this week’s guest, Ana Rodriguez, and her colleagues adds to the evidence that single-dosing is possible and protective against pre-cancerous cervical lesions.

Cancer article

Cancer editorial 

An earlier (2015) podcast on the question of the number of vaccine doses needed to confer protection

Running time: 16 minutes

February 13th, 2020

Podcast 252: We revisit our chat about chatting about guns

(2 votes, average: 3.00 out of 5)

Back in November, Ali Raja and Joe Elia talked with Garen Wintemute about his Health Affairs paper regarding addressing the topic of guns with patients.

Having encountered another of those weeks in which interviewees were either on vacation (richly deserved, we’re certain) or too busy to respond to Joe’s requests (get some sleep!), we’re going to offer that conversation again. We hope you’ll listen and vote — and if you do vote, please leave a comment as well.

URL for November’s original podcast

Running time: 19 minutes

February 7th, 2020

Podcast 251: Intermittent fasting

(17 votes, average: 3.35 out of 5)

Intermittent fasting has salutary effects. Listen how Dr. Mark P. Mattson, co-author of a recent NEJM review on the topic, assesses the practice — and how he’s managed to skip breakfast for the past 30 years or so.

Dr. Ali Raja joins Joe as co-host again this time.

Links:

de Cabo and Mattson’s review in the New England Journal of Medicine

Michael Mosley and Mimi Spencer’s book “The FastDiet”

Running time: 18 minutes

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