Jama Clinical Reviews: Interviews About Ideas & Innovations In Medicine, Science & Clinical Practice. Listen & Earn Cme Credi

Some drugs and devices receive accelerated approval from the FDA in order to provide potentially important treatments for patients when effective therapies may not be available. These drugs or devices are supposed to have postmarketing studies to definitively show their efficacy or safety, but sometimes this doesn't happen. Rita F. Redberg, MD, MSc, Aaron S. Kesselheim, MD, JD, MPH, and Robert M. Califf, MD, discuss their articles characterizing studies used for the approval of high-risk medical devices and accelerated approval of drugs by the FDA. Discussed in this podcast: FDA Online

Scott Grundy, MD, PhD, is a professor of medicine at UT Southwestern in Dallas and is one of a small group of investigators who saved statins from being dumped as a potential drug class. Dr Grundy tells the story of how studying patients with familial hypercholesterolemia unraveled the mysteries of high cholesterol levels. This resulted in the development of very effective drugs to treat any patient with high cholesterol. Familial hypercholesterolemia is fairly common and when patients have very high cholesterol levels they and their families should undergo cascade screening. Interviewees: Scott M. Grundy, MD, PhD, and author Joshua W. Knowles, MD, PhD Links discussed in this episode: Cascade Screening for Familial Hypercholesterolemia and the Use of Genetic Testing Dietary Guidelines for Americans Interview with Karen DeSalvo, MD, MPH, MSc, author of Dietary Guidelines for Americans

Asthma often develops in childhood but also affects a significant number of adults. It can present in various ways and with varying degrees of severity. William J. Calhoun, MD, of the University of Texas Medical Branch, Galveston, discusses the approach to diagnosis and provides tips for management of this common condition.

Following placement of cardiac stents, patients receive dual antiplatelet therapy (DAPT) to prevent stent thrombosis. Prevention of thrombosis is offset by a risk of bleeding. The optimal balance between thrombosis prevention and bleeding risk is not always known. How to go about optimizing DAPT therapy is discussed by Glen Levine, MD, professor of medicine at Baylor College of Medicine in Houston, Texas, and chair of the combined American College of Cardiology/American Heart Association Guideline Committees.

Allergy to penicillin is one of the most commonly reported allergies by patients. In reality, true penicillin allergy is uncommon. Dr. Elizabeth Phillips from Vanderbilt University discusses her experience with testing for penicillin allergy in patients who thought they had this problem.

Multiple guidelines have been issued regarding how aggressively cholesterol should be managed. These guidelines do not agree with one another and the most significant area of disagreement is in recommendations for high intensity statin therapy. In this podcast we discuss this issue with a number of experts in the field to help better understand how high-intensity statin therapy might be applied to patient care.

Chromosomal microarray technology (CMA) facilitates the genetic diagnosis of intellectual disabilities, autism spectrum disorder, and congenital abnormalities in children. Previously, G-band karyotyping was the test performed for this purpose but it could only identify very large chromosomal abnormalities and was not very sensitive. Being a molecular rather than microscopic technique, CMA is far more sensitive for identifying genetic abnormalities and is now the test of choice. We interview David H. Ledbetter, MD, and Christa Lese Martin, PhD, from Geisinger Health System, authors of this JAMA Insights article. Articles discussed in this episode: Chromosomal Microarray Testing for Children With Unexplained Neurodevelopmental Disorders New Approaches to Molecular Diagnosis

Depression is very common in old age. Because it is associated with many issues related to aging such as having diabetes, hypertension, and other diseases and also the general ability to do less than when a person was younger, it is often assumed that depression is just part of the aging process. Inadequate treatment is often given for depression, frustrating patients and clinicians. However, aggressive depression treatment in elderly individuals can be very successful and greatly improve an older person’s quality of life. PHQ-9 USPSTF recs JAMA Patient Page on Screening for Depression

Whole-genome sequencing is now easily done for very little cost. It is not known how to interpret the results of this testing. It is inadvisable for healthy individuals to undergo routine whole-genome sequencing but if someone has a reason to suspect a particular disease known to be associated with a unique gene, then targeted genetic sequencing is reasonable. Interviewee: James P. Evans, MD, PhD, from the University of North Carolina at Chapel Hill.

Much has changed recently in diabetes management. The treatment goal has shifted from rigorous glucose control with HbA1c as the primary target to cardiovascular risk reduction. Risk reduction can be achieved in a variety of ways and does not necessarily depend on expensive new drugs that were shown to achieve this end point. Older, cheaper drugs may achieve the same goal but were never tested in this context. Interview with JoAnn E. Manson, MD, PhD, from Brigham and Women's Hospital in Boston and Jane Reusch, MD, from University of Colorado, Denver. Article: Reusch JEB, Manson JE. Management of type 2 diabetes in 2017: getting to goal. JAMA. 2017;317(10):1015-1016. doi:10.1001/jama.2017.0241

A resident is asked to remove a drain that was placed in the lumbar space during an operation. Having never seen this sort of drain before not having removed one, the resident proceeded to remove the catheter. Several days later, the patient complained of persistent drainage. An 11-cm segment of retained catheter was removed. This JAMA Performance Improvement article discusses how to avoid this sort of problem as well as how to ensure that resident physicians have sufficient skills to perform procedures on their own. We talk with Drs Cynthia Barnhard, John DeLancey, authors of Retained Lumbar Catheter Tip, and Dr Aaron Reynolds and Dr David Baker. Related article: Retained Lumbar Catheter Tip  

Alzheimer disease causes progressive neurologic deterioration and is reasonably common in elderly patients. It is characterized by specific patterns of memory loss, which progressively worsens and for which there is no treatment. Recent drug trials have been disappointing in that promising medications have failed to affect the disease. Interesting new hypotheses have emerged from basic science research suggesting that the neurofibrillary tangles characteristic of Alzheimer brain lesions form in response to infection of the brain. Interview with Rudolph Tanzi, PhD, of Harvard University; Berislav Zlokovic, MD, PhD, of the University of Southern California; and Andy Josephson, MD, of the University of California San Francisco, and editor of JAMA Neurology. Related article: Alzheimer Outlook Far From Bleak

Recent guidelines for how to best manage septic shock have changed. Gone are recommendations for central venous oxygen saturation monitoring and goal-directed therapy. In is the concept that septic shock be treated as an emergency with rapid administration of antibiotics and large amounts of fluids. Our discussants Derek C. Angus, MD, MPH, and Michael D. Howell, MD, MPH, discuss why these recommendations have changed. This is the second podcast in the Surviving Sepsis guideline series. The first podcast reviewed what recommendations are in the guideline itself. Article discussed in this episode: Management of Sepsis and Septic Shock Speakers: JAMA Associate Editor Derek C. Angus, MD, MPH, University of Pittsburgh, and Michael D. Howell, MD, MPH, University of Chicago.

In 2017 the Society for Critical Care Medicine updated its guidelines for sepsis management. These new guidelines differ significantly from ones in the past in that they no longer recommend protocolized resuscitation and emphasize early and aggressive fluid resuscitation when patients present with septic shock. This is the first podcast in the Surviving Sepsis guideline series. The next episode discusses why the new sepsis guideline changed. Article discussed in this episode: Management of Sepsis and Septic Shock Speakers: Laura Evans, MD, MSc, of Bellevue Hospital and NYU Medical Center Andrew Rhodes, MBBS, MD, of St George’s University Hospitals NHS Trust and co-chair of the Surviving Sepsis guideline panel Mitchell M. Levy, MD, of the Alpert Medical School of Brown University and Rhode Island Hospital    

Approximately one-third of all medical school graduates report having been abused as students. Medical student and resident abuse has long been considered unacceptable behavior but still persists in the teaching environment. In this podcast we discuss how students and residents might respond to these events. We interview Geoffrey Young, MD, from the Association of American Medical Colleges and Thomas J. Nasca, MD, from the Accreditation Council for Graduate Medical Education, who discuss how they expect medical schools to respond to abusive behaviors and what resources are available to students and residents who have been abused to report those experiences without fearing retribution. Article discussed in this episode: Medical Student Mistreatment  

As people age, loss of muscle mass is inevitable, resulting in sarcopenia. Muscle loss contributes to overall weakness, which causes frailty. Frailty, in turn, is the generalized susceptibility to disease and injury, all of which causes loss of autonomy. Because of the potential for progressive decline in physical function in very elderly patients, accurate tools are needed to predict mortality risk to individualize treatments intended to improve longevity such as chemotherapy, management of chronic diseases, and surgery. In this podcast, sarcopenia, frailty, and risk prediction are discussed in the context of major trials studying them being conducted in Europe.

Managing hypertension in elderly patients is complicated. Recent studies have shown that elderly patients may benefit from aggressive hypertension management, but other studies have shown that some are harmed by overly aggressive hypertension management. These issues were discussed in detail at the 2016 European Union Geriatric Medicine Society meeting. In this podcast we discuss how to best manage hypertension in elderly patients with Athanase Benetos, MD, PhD, a professor of internal medicine from Nancy, France, and the academic director of the European Union Geriatric Medicine Society. Older patients tend to have multiple comorbid conditions requiring treatment with many medications. Managing polypharmacy is challenging. In this podcast we discuss 2 tools that help deal with this problem: The Beer’s list and the START/STOPP criteria. To help understand these tools we spoke with Michael Steinman, MD, a professor of medicine from University of California-San Francisco, and Denis O’Mahony from University Coll

Workplace violence–related injuries occur disproportionately in health care settings. In this podcast, we discuss how individual clinicians should manage violent patients who might attack them. Article discussed in this episode: Ensuring Staff Safety When Treating Potentially Violent Patients

Between 8% and 10% of the population will have a seizure at one point in life. It's important to distinguish seizures from other entities that can look like them and, once a diagnosis of a seizure is established, know how to treat them. In this podcast we discuss seizures and epilepsy with Jay Gavvala, MD, author of New-Onset Seizure in Adults and Adolescents: A Review. Article discussed in this episode: New-Onset Seizure in Adults and Adolescents: A Review  

Medicare recently developed a star rating system to help consumers determine the quality of care delivered at various hospitals. This rating system was considered controversial by many. In this podcast we discuss the rating system with one of its critics, Karl Y. Bilimoria, MD, MS, and with Kate Goodrich, MD, the Director of the Center for Clinical Standards and Quality at Medicare. Article discussed in this episode: The New CMS Hospital Quality Star Ratings: The Stars Are Not Aligned