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Dip and climb is a win if you're transfusing blood, but a big loss if you're talking all-cause mortality. What's dragging down life expectancy in the US?
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Despite climbing ever upward in other high income countries, US life expectancy stalled around 2010. Gains from the previous decade's fight against ischemic heart disease and cancer so abruptly changed course that by 2014 life expectancy started falling. Don't blame kids or grandparents: infant and adolescent mortality rates declined from 1999 - 2017, as did mortality for elderly Americans. Young and middle-aged adults, however, have seen problems.
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A mash up of records from the US Mortality Database and CDC WONDER places drug overdoses – and by extension, the opioid epidemic – at the forefront of increased middle-aged mortality. From 1999 - 2017 adults aged 25 - 64 years saw overdose deaths increase by 400% (7 deaths per 100,000 in '99 vs. 33 in 2017). The same population saw increases in alcoholic liver disease (40%), suicides (38%), and metabolic syndrome-related diseases like hypertension and diabetes. All told, there were 33,000+ excess deaths among middle-aged Americans between 2010 and 2017.
JAMA
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Yet another troubling reason why the opioid crisis demands our full attention. Since about 1/3 of excess deaths came from 4 Ohio Valley states, there's room for action on a national and local level.
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When day and night are the same to whoever schedules ED shifts
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There are still key differences: the HYGIA Chronotherapy Trial compared bedtime vs. morning BP med dosing in 19,000 hypertensive patients. The bedtime group saw 45% fewer CV events over 6-year follow-up, and results were significant across all 5 primary outcome endpoints: CV death, MI, coronary revascularization, heart failure, and stroke. Through ambulatory blood pressure monitoring, bedtime dosing was shown to improve nighttime BP and restore appropriate BP dipping responses during sleep.
Eur Heart J
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When you send the med student to do the ABG
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Probably unnecessary, borderline hazardous. The same goes for excess imaging: a trial of 2,000 patients under evaluation for pulmonary embolism (PE) found that PE could be safely excluded in patients with low clinical pretest probability (PTP) and d-dimer < 1,000 ng / mL or moderate PTP with d-dimer < 500 ng / mL. There was no incidence of VTE over 3 month follow-up, and fewer patients needed CT angiography (34% vs. 52%) compared to conventional care.
NEJM
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When you'll do anything, as long as you don't have to get out of bed
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A CDC-funded trial used internet banner ads to recruit 2,660 men who have sex with men (MSM) to a trial comparing free at-home HIV self-testing to usual care. The self-testing group tested more frequently than controls (76% vs. 22% completed ≥ 3 tests), and twice as many new infections were identified (1.9% vs. 0.8%) in the self-testing group over 1-year follow-up.
JAMA Intern Med
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Diagnostic delay is a big theme in hemochromatosis, where symptoms start slowly and are often clinically mundane. The disease can manifest anywhere from adolescence to mid-life. Chronic fatigue and joint pain are among the earliest clues, though it can take years for end-organ damage from iron overload to become apparent. Send for transferrin and ferritin if you have clinical suspicion. If both are normal or below normal the disease is ruled out.
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For iron-MRI to quantify iron overload? Liver biopsy was long ago tossed in favor of noninvasive MRI imaging after studies from 2004 and 2005 demonstrated that MRI could sensitively and specifically predict liver iron concentration. Even with positive imaging, make sure to rule out acquired iron overload before searching for a genetic cause.
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What your ob-gyn friends are talking about
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We're not that sure we'd want a hormone-releasing capsule in our stomach for a month, but that's the strategy behind a female contraceptive pill now shown to work in pigs. A male contraceptive pill passed phase I studies earlier this year.
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