geoffrey modest medical blogs

am acad of pediatrics published clinical practice guideline on diagnosis and management of acute otitis media -- AOM  (see  otitis media guideline peds 2013  in dropbox).  several points:   diagnosis: --should dx AOM in kids with moderate to severe TM bulging or new onset otorrhea not due to external otitis. --can dx AOM in children with mild TM bulging and <48 hour onset of ear pain or intense erythema of the TM --Not dx AOM if no middle ear effusion (eg, by pneumatic otoscopy or tympanometry)   management: --should prescribe abx if severe AOM in kids >6months old, with mod or severe otalgia, or otalgia for >48hrs or T>39C / 102.2.F --should prescribe abx in kids 6-24 months old with bilateral AOM without severe sx (eg mild otalgia <48hrs and temp <39C /102.2F) --either abx or observation in kids 6-24 months old with non-severe unilateral AOM.  caveat is that observation appropriate only if mechanism in plac...

Nejm with article on mediterranean diet in primary prevention (see  cad prevent mediterranean diet nejm 2013  in dropbox), as follows:   --7500 spanish patients aged 55-80, 57% women, with high cardiovascular risk (type 2 dm, or at least 3 risk factors of smoking, htn, inc LDL, low HDL, overwt/obese, or fam hx premature cad) but no evident cardiac disease. Other baseline characteristics: 40% on statins, 20% on antiplatelet rx, 50% on ACE-i. pts assessed for primary outcome of major cardiovasc event rate (MI, stroke, of death from cardiovasc causes). put on one of 3 diets:         -mediterranean with extra olive oil (given 1 qt of extra-virgin olive oil/week)         -mediterranean with extra mixed nuts (given 30 g mixed nuts/day)                -control diet (advise to reduce dietary fat). --study stopped early, after 4.8...

Subgroup analysis of the ACCOMPLISH trial found decreasing benefit of the benazepril/hctz combo pill vs benazepril/amlodipine combo in progressively lower BMI patients (see  htn ccb better than hctz in nonobese lancet 2013  in dropbox).  So, here's the skinny...   Secondary analysis of 11400 pts randomized to either of the above meds being treated for systolic htn (ave around 146/80 pretreatment), with primary outcome of cardiovasc death, nonfatal MI or stroke, with results below per 1000 pt-yrs :         --by BMI, those on combo of benaz/amlod (average titrated dose 36/8 mg, leading to bp on treatment of approx 133/72)                 -- for normal BMI (<25):30.7                 -- for overwt (BMI bet 25 and 30): 21.9         ...

The point of this email is to present some of the new literature on hypertension, which could impact clinical practice.  The summaries below are quite brief, but lots of info in the articles.   NICE  (National institute for health and clinical excellence, in the UK, which sends out recommendations for many clinical issues -- well-researched and probably less influenced by pharmaceutical money, etc -- see  htn nice recs 2011  and  htn nice recs summary 2011  in dropbox).  These are very thoughtful guidelines with some major changes over JNC here (though rumor has it that a revised JNC is on the near horizon). A few very notable changes:   --hctz should not be first line, and that in general, ccb's be used first line in people over 55yo and in african-caribbean patients, while ace/arb's be used in under 55yo non-african descent (use with care for women who might become pregnant, though there was an article suggesting that ACE-I not so ...

in the midst of the anti-cholesterol panic over the past few decades, there were a couple of notable studies (like the nurses health study in the 80's to 90's) which found the unexpected finding that egg consumption (ie, cholesterol) was not associated with CAD events.  it has been clear for a long time that saturated fats increase serum cholesterol levels close to 3 times than of consuming cholesterol itself, and that trans fats  increase serum cholesterol about 10x  more  than cholesterol consumption. however, the popular culture, reinforced by the medical and nutrition establishments, suggested a strict avoidance of cholesterol ( with eggs as  perhaps  the major  villain ), with perhaps more leniency to other (and more pathologic) foods, such as trans and saturated fats.   in this light, meta-anal in bmj (see  cad egg consumption bmj 2013  in dropbox) which assessed 264K people for CAD and 210K for stroke, with 5847 cas...

Not a lot of data around about combo hypertensive drug interactions assoc with acute kidney dz. We know that NSAIDs are assoc with kidney dz through their inhib of prostacyclin synthesis (and assoc renal afferent arteriolar vasoconstriction). ACE-I/ARBs assoc with dec glomerular filtration (from efferent arteriolar vasodilation). Diuretics assoc with hypovolemia. So, this study done which looked at huge database of pts with htn in the UK -- clinical practice research datalink, with almost 500K people on antihypertensives and follow up of 6 years (See  htn nsaid plus ace diur inc kidney injury bmj 2013  indropbox). They linked pts in their electronic database with those who were admitted to the hospital for acute kidney injury as their admitting diagnosis. They assessed use of NSAIDS and which antihypertensives the pts were on, in a nested case-controlled study.  Results:   -- 2215 cases of acute kidney injury (7/10,000 person-yrs) --double combination therapy ...

No big shocker.  Turns out the statins and increased exercise fitness are synergistic in mortality benefit in study of veterans (see cad  statin and fitness additive lancet 2013  in dropbox).  In brief:   --10K people, median age 59, who had ETT between 1986-2011 (these results were used to determine their fitness, based on peak MET achieved) and reviewed for use of statins, followed ave of 10 years. This was just number-crunching analysis (people may have gotten their lipids checked routinely or to assess ischemia sx and happened to have an exercise test for whatever reason)   --primary outcome all-cause mortality --ave chol pretreatment was the same (232) as well as HDL (46) and LDL (154), though chol decreased in those on statins (170 vs 197) and LDL (100 vs 139) without change in HDL --mortality rate was 18.5% in those on statins vs 27.7% on those not. --in those on statins: those most fit had 70% lower mortality than those least fit. -...

New york times today shows that drug company shenanigans know no bounds (ie, not just in US!!).  Johnson and Johnson seems to have paid off Novartis to keep them from releasing a generic version of fentanyl in the Netherlands.  See link below.  Geoff   http://www.nytimes.com/2013/02/01/business/global/eu-says-drug-makers-paid-to-delay-generic-version.html?nl=todaysheadlines&emc=edit_th_20130201&_r=0