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    Science

    Sensible Medicine

    Common sense and original thinking in bio-medicine
    A platform for diverse views and debate

    www.sensible-med.com

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    Copyright: © Editors

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    Latest Episodes:
    Friday Reflection 31: Senses, Memories, and Medicine Oct 20, 2023
    Show notes

    Friday Reflection 31: Senses, Memories, and Medicine

    Medical training introduced me to a whole menu of smells -- both diagnostic tools and reminders of times in my career.


    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Sudden cardiac death and arrhythmias in athletes Oct 18, 2023
    Show notes

    Sudden cardiac death due to ventricular rhythm disturbances are rare but highly public. It’s strange and curious because you don’t expect healthy athletes to suffer serious cardiac issues.

    Recently three prominent athletes have survived sudden cardiac death. Christian Erikson, a Danish soccer player, Damar Hamlin, an American football player and Bronny James, son of Lebron James. These high-profile cases have highlighted the issue of sudden cardiac death of athletes.

    Dr. Dorian has published extensively on this topic. We had a great conversation. I learned a lot and hope you will too.

    JMM

    Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.

    Here are three pertinent articles he has published—note the first is from NEJM.

    Landry CH, Allan KS, Connelly KA, Cunningham K, Morrison LJ, Dorian P; Rescu Investigators. Sudden Cardiac Arrest during Participation in Competitive Sports. N Engl J Med. 2017 Nov 16;377(20):1943-1953. doi: 10.1056/NEJMoa1615710. PMID: 29141175; PMCID: PMC5726886.

    Weissler Snir A, Connelly KA, Goodman JM, Dorian D, Dorian P. Exercise in hypertrophic cardiomyopathy: restrict or rethink. Am J Physiol Heart Circ Physiol. 2021 May 1;320(5):H2101-H2111. doi: 10.1152/ajpheart.00850.2020. Epub 2021 Mar 26. PMID: 33769918.

    Weissler-Snir A, Allan K, Cunningham K, Connelly KA, Lee DS, Spears DA, Rakowski H, Dorian P. Hypertrophic Cardiomyopathy-Related Sudden Cardiac Death in Young People in Ontario. Circulation. 2019 Nov 19;140(21):1706-1716. doi: 10.1161/CIRCULATIONAHA.119.040271. Epub 2019 Oct 21. PMID: 31630535.


    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Prasad's lecture gets cancelled/ Cifu Gets COVID Oct 16, 2023
    Show notes
    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    New Podcast -- Discussion with Rita Redberg and Angela Lu regarding Their Study on Conflict of Interest Oct 05, 2023
    Show notes

    Angela Lu is training to be a physician. She’s interested in public policy. As a third year medical student, she teamed up with established leaders to ask a unique question regarding public disclosure of financial relationships.

    When the Centers for Medicare & Medicaid Services (CMS) issues National Coverage Determinations (NCDs) for services or products, they mean business. Such decisions have huge implications. You cannot go against them. Think #HighConsequences.

    CMS studies the evidence and publishes a proposed decision. It then allows public comments. People care.

    The idea behind their study, which made it into the Journal of the American Medical Association, was to study how many commenters disclosed their financial conflicts.

    Dr. Lu went through more than 680 comments submitted on 4 NCDs—all of which were high cost invasive procedures.

    I won’t spoil the conversation, but they found a very high percentages of comments asking to expand indications for these procedures and very very low percentages of people who disclosed their relevant relationships. This study was made possible by the Open Payments database.

    One important note: disclosure of relationships was voluntary. Enjoy the conversation. Thanks for listening. JMM


    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Foy and Mandrola Talk Coronary Calcium and a New Super-Exciting Approach to Medical Education Sep 27, 2023
    Show notes

    Andrew Foy rejoins the Sensible Medicine podcast. We talk first about coronary artery calcium. Andrew is an expert in this area.

    We have co-written our case against CAC scoring for any cause in the American Family Physician. It’s had little effect as CAC scoring is running rampant.

    Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.

    The second part of our conversation centers on a big med-ed project Andrew is co-leading at Penn State. He calls it Argue-to-Learn.

    The idea is to expose pre-clinical students to the value of civil debate. Here is their paper: Student Perceptions of a New Course Using Argumentation in Medical Education

    Here is a quote:

    The absence of argumentation (i.e., a productive exchange of opposing views aimed at improved understanding of a given issue) in medical education may leave physicians susceptible to medical marketing, and incapable of both resolving industry claims and adapting to changing paradigms.

    Gosh. Gosh. Double Gosh, this is an exciting effort. Listen to Andrew explain.

    JMM


    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Foy and Mandrola Discuss AF, AF-Ablation, Sham-controls, Evidence Translation and Heterogenous Treatment Effects Sep 19, 2023
    Show notes

    This week, I talk with Andrew Foy, who is an academic cardiologist at Penn State University in Hershey, PA. Andrew is one of the smartest voices in medicine today.

    We start with the REMEDIAL trial, published recently in JAMA. Ablation vs Meds. Primary endpoint—depression and anxiety. One of the main issues was the control arm—namely that there was no sham control.

    We referenced this useful review paper on placebo and nocebo effects in cardiology, from Brian Olshansky.

    Our second topic was the FRAIL AF trial.

    This was frail, elderly patients who had AF and were stable on Vitamin K antagonists (similar to warfarin) were randomized to remain on the VKA or switch to a direct acting oral anticoagulant. Primary endpoint—major bleeding.

    FRAIL AF is in Andrew’s wheelhouse as one of his primary academic areas of study is the role of multi-morbidity in translating medical evidence.

    He mentions a term called heterogenous treatment effects or HTE. I don’t love the term because it’s heavy into jargon. But HTE is super important for using evidence in the clinic. Andrew explains it well.

    Here is the editorial Andrew co-authored regarding another important trial in elderly patients who were having NSTEMI.

    I have written about FRAIL AF on Medscape and Sensible Medicine.

    We were going to talk about coronary artery calcium screening, but we had talked enough and will do a separate podcast on CAC.

    Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.

    As always, let us know what you think. We appreciate the support. Thank you. JMM


    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Coumadin beats DOAC, ECMO fails, When RCTs needed, Bad COVID Policy Sep 11, 2023
    Show notes
    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Friday Reflection 29: The Totally Predictable Doctor as Patient Essay Sep 08, 2023
    Show notes
    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Sensible Medicine x Vaccine Curious: Tracy Beth Høeg and Christine Stabell Benn compare US & Danish COVID-19 response and child vaccination policy Aug 29, 2023
    Show notes

    Sensible Medicine

    Sensible Medicine x Vaccine Curious Cross Podcast on the USA vs Denmark, vaccines, etc:

    Show notes by Dovid Y Rimmer, Tracy Beth Høeg and Christine Stabell Benn

    * Benn, Høeg. Regarding becoming a medical skeptic. Hoeg: anonymous blog - exercise during pregnancy. Benn: Vitamins, sex differences, and vaccines.

    * Differences in pandemic response between Denmark v. California - school reopening, masks.

    * USA recommends boosters (yearly) for Children, Denmark does not recommend vaccinating children

    * Benn: Op-ed recommending gradual herd immunity.

    * Høeg, Duriseti, Prasad NEJM letter: Observational data for Covid mortality in vaccinated + boosted population (Source the original study, raw data release in response to letter, and Prasad NEJM letter).

    * Chandra & Høeg reanalysis of MMWR study: Differences in Covid-19 between schools mandating masks and not mandating. MMWR did not publish reanalysis, published in Journal of Infection.

    * Høeg et al reanalysis of Cowger et al. in NEJM, differences between schools mandating masks and not mandating in Boston, MA.

    * Six Clalit Health studies from Israel published in prestigious medical journals - the studies did not release their data or analyses to the public. (What were the points they made that influenced policy decisions, where were they cited, altimetric score. i.e. note that they were effective influencing policy without transparency).

    * Childhood vaccination schedules: Denmark 18 doses and USA 50 doses vaccination schedules. Note: differences regarding Influenza, Hep A & B, Varicella, Meningococcal, and Covid-19 which may be added to a yearly schedule. Denmark and Sweden don’t recommend yearly influenza vaccine in non high-risk under 65.

    * Denmark requires benefit for children, Finland allows societal considerations such as socioeconomic component of rotavirus. Finland uses influenza vaccine. And Denmark might introduce flu vaccine to reduce the flu burden on the elderly.

    * Ethics of consequentialist vaccine policy.

    * Pandemrix Swine flu vaccine had an adverse effect event of narcolepsy (hundreds of children affected), Denmark was spared some of the consequence by limiting its recommendation to vulnerable children only.

    * Flu deaths approximately 2-4/million, amongst children (Norway, US).

    * Nordic countries were hesitant to recommend routine Covid-19 vaccination. Denmark admits it was a mistake to recommend vaccinating children (it was done for the adults and since the vaccine was leaky it made no difference, everyone got it anyway).

    * Norway found in their pandemic investigation 6 weeks school closure was ‘a mistake’.

    Key academic claims:

    * Benn paper on Covid-19 becoming a childhood disease.https://www.bmj.com/content/374/bmj.n1687/rr-8

    * Benn: Predictably Covid-19 would be dangerous only to old, vulnerable, and those with a large viral inoculum.https://pubmed.ncbi.nlm.nih.gov/32146445/ and https://pubmed.ncbi.nlm.nih.gov/6741923/

    * Benn: Non-trivial C19 Death amongst elderly, but it probably didn’t change the amount of years they lived. https://pubmed.ncbi.nlm.nih.gov/33137809/

    * The greater the inoculum the more harmful the disease. Example: measles index cases v. https://pubmed.ncbi.nlm.nih.gov/6741923/

    * Covid-19 harms, are rare in children. Actual risk to children prior to natural immunity and afterward (Ideally include all risks, Death, hospitalization, severe disease). ​​https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9613797/, risks of severe disease https://pubmed.ncbi.nlm.nih.gov/35962242/

    * Even rare harms would outweigh the benefits of widespread childhood vaccination. https://www.bmj.com/content/374/bmj.n1687/rr-8

    * Amongst most viruses the 2nd infection is less pathogenic.

    * Harms of lockdown exceeded benefits in quality studies, some non quality studies might indicate otherwise. https://www.tandfonline.com/doi/full/10.1080/00779954.2020.1844786?src=recsys, https://www.tandfonline.com/doi/abs/10.1080/13571516.2021.1976051

    * Measles index cases (Child contracts the virus at school) results in more mild disease, family transmission is more severe with 4x fold mortality. https://pubmed.ncbi.nlm.nih.gov/6741923/ This has also been shown in animal studies https://pubmed.ncbi.nlm.nih.gov/36992457/. Epidemiological studies: Secondary cases (Family transmission) for Pertussis, https://pubmed.ncbi.nlm.nih.gov/11798255/ Varicella https://pubmed.ncbi.nlm.nih.gov/15702036/ and other viruses are worse than index cases i

    * Hoeg: MMWR School transmission of c19 is rare: https://www.cdc.gov/mmwr/volumes/70/wr/mm7004e3.htm


    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

    Friday Reflection 28: Four of the Things Patients Have Taught Me Aug 25, 2023
    Show notes

    Although it is unoriginal to point out that doctors learn from our patients, here are a few lessons so powerful, so extrapolatable, that I forever associate them with an individual.


    This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

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