Sep 14, 2018

Dairy dreams

The story

Dietary guidelines have long frowned on whole-fat dairy. New evidence says that may be a mistake.

The background

Dairy staples like yogurt, cheese, and cafeteria soft serve are high in saturated fat. But there's enough other stuff in a glass of milk (think: bioactive proteins, other fat groups, even probiotics) to justify a morning latte. The mammoth PURE study aims to tackle big questions in nutrition by linking self-reported dietary intake with long-term outcomes. Results from last year matched high-carbohydrate intake with a higher risk of total mortality, but some criticized the authors for oversimplifying macronutrients. Many feel that individual food groups are a better fit.

The whole milk

High dairy consumption (≥ 2 servings a day) was associated with a 16% decrease in cardiovascular disease and a 17% decrease in total mortality over 9-year follow-up. This PURE cohort featured over 130,000 participants from 21 low and middle-income countries across 5 continents. Milk and yogurt consumption drove the positive outcomes, and both were more protective in whole-fat form. Butter and cheese intake didn't contribute. A key caveat is that almost all of the countries in the study had lower baseline dairy intake than the United States.

The takeaway

We'd love to know what the data would look like in a US-based context, but the strong signal for whole-fat dairy is encouraging and among the best pieces of evidence on the subject to date. 

Say it on rounds

When the overnight pharmacy gives you the green light

Don't hold back. Carbapenem-resistant superbugs are on the rise, and many are trying to figure out how to limit use of meropenem to eliminate resistance. Unlike most clinical situations, the answer isn't Zosyn. A study designed to assess for non-inferiority found that patients with confirmed ceftriaxone-resistant E. Coli and Klebsiella bacteremia had greater 30-day mortality (12% vs. 4%) when treated with upfront Zosyn compared to meropenem. Adverse events like C. diff and subsequent infection with carbapenem-resistant organisms were similar between groups.

When your empty clinic slot becomes a surprise new patient visit

Medicine is fraught with unintended consequences. Take pressors and ICU-acquired weakness (ICU-AW): a secondary analysis of 170 critically ill, vented patients from a trial of early physical therapy found that the use of vasoactive medications increased the odds of developing ICU-AW by about 3x independent of other risk factors. The authors suggest that excess adrenergic stimulation may harm skeletal muscle.

When your old suit feels tighter this interview season

No need to take extreme measures. But be aware that endoscopic weight loss procedures are evolving and can be performed with same-day discharge. A single-center study that compared endoscopic sleeve gastroplasty (ESG) to laparoscopic sleeve gastrectomy (LSG) found that while ESG produced less total body weight loss at 6 months than LSG (17% vs 24%), there were fewer adverse effects (5% vs. 17%) in the ESG group. ESG patients also had a lower rate of new-onset GERD. Check out this video for an illustration of the procedure.
Gastrointest Endosc

Brush up

Aspirin-exacerbated respiratory disease (AERD)

AERD affects about 7% of asthma patients with a median age of onset of 30. Look for rhinorrhea, cough or wheezing within 90 minutes of NSAID use in patients with asthma and recurrent nasal polyps. Symptoms are also common after red wine or beer. The underlying mechanism involves unopposed mast cell activation due to COX-1 inhibition, so specific COX-2 inhibitors like celecoxib or low-dose meloxicam are safe to use.

What's the evidence

For aspirin desensitization in AERD? A 2015 study randomized 34 patients with aspirin-intolerant asthma to placebo or aspirin desensitization over two days followed by twice-daily aspirin for 6 months. Symptom scores improved dramatically in the aspirin group, though immunologic markers were unchanged. Though counterintuitive, daily aspirin therapy serves as routine maintenance for AERD after desensitization.

What your reproductive health friends are talking about

In one of the few moves creepier than the uninvited shoulder rub, fertility clinic doc Donald Cline substituted his own sperm for what he told patients was sperm from anonymous donors. He's now known to have 36 biological children and counting.

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Send your interns something to look forward to


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