geoffrey modest medical blogs

new guidelines on management of atrial fibrillation from am heart assn and am acad of cardiol  (see  afib aha guidelines circ 2014  in dropbox, or 10.1016/j.jacc.2014.03.022). long article, so will summarize a few of the newer or more significant recommendations: 1. antithrombotic therapy -- individualized/shared decision-making.           -- warfarin if mechanical valve (range 2-3 or 2.5-3.5, depending on type of valve/location).           -- for patients with nonvalvular afib with prior stroke, TIA, or CHA2DS2--VASc score of 2 or greater, recommend oral anticoag. [note they are not using the older CHADS2 score.  see below for the  CHA2DS2--VASc instrument.]  options: warfarin with INR 2-3 (level of evidence A); or dabigatran, rivaroxaban, or apixaban  (level of evidence B) [ie, they added these factor Xa inhibitors to the list.  though i have sent out recent blogs on the apparent understating of risks of dabigatran in particular]. not use dabigatran in patients with mechanic

one of the BMC preceptors asked for my assessment of the shenanigans around rosiglitazone and what we should do (thanks, dan).  so, here is my sense: 1. FDA initially restricted rosiglitazone because of very large meta-anal showing increased cardiac events 2. the RECORD study (Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of glycemia in Diabetes study) did not find increased cardiac risk after 3.75 yrs.  re-eval was done at 5.5 years just published in A ugust (see   dm RECORD trial amhrtj 2013  in dropbox, or doi.org/10.1016/j.ahj.2013.05.004) .  see point 3  below, but the FDA gives lots more weight to this type of trial looking at cardiac outcomes, vs secondary analyses 3. so, they lifted their restriction. but,... 1. rosiglitazone is not nearly as good as pioglitazone for lipids. for example, a study of 400 people off all other diabetes meds were randomized to pioglitazone vs rosiglitazone. results at 24 weeks:     --no diff in A1c     --fast

a recent animal study assessed the effects of cannabinoid receptor stimulation on adolescent rats, finding  brain  changes similar to those found in schizophrenia (see   marijuana brain effects rat molec psych 2014   in dropbbox, or   http://dx.doi.org/10.1038/mp.2014.14 ). this study adds physiologic plausibility to the observed increased incidence of psychosis in human marijuana users in observational cohort studies (see article below). given the current remarkable increase in marijuana potency, increasing usage overall, and new legalization, i thought it was useful to review some of the newer data on adverse effects, concentrating on the psych ones. it is notable that the onset of both addiction-related syndromes and psychosis typically occur in adolescence. in the rat study (i will not go into all of the gory details):           --rats with persistent stimulation of the cannabinoid 1 receptor, but only during specific windows of adolescence (ie, only in early or mid adolescenc

there are a plethora of articles on the potential benefits of vitamin d. as noted in many prior blogs, vitamin d receptors exist throughout the body. some vitamin d benefits are well-documented (bone, muscle, decrease in falls in elderly), some have small studies to support (improved response of TB to medications in those with adequate vitamin d levels, improved glucose tolerance), and many are epidemiologic studies (cancer -- including prostate, breast, ovary; all-cause mortality; immunologic function and decrease in immunologic diseases -- eg multiple sclerosis; heart disease,...) -- for example,   see  vit d. Endocrine Guidelines 2011  in dropbox, or doi: 10.1210/jc.2011-0385 for the endocrine society recommendations. the present article  (see  vit d and lipids menopause 2014  in dropbox, or DOI: 10.1097/gme.0000000000000188)  supports a role in cholesterol profiles, from the Women's Health Initiative calcium/vitamin D randomized trial. in brief,  --600 postmenopausal women

choosing wisely came out with 10 tests/treatments that pediatricians/fam practice/ER providers should question (see  http://www.choosingwisely.org/wp-content/uploads/2014/03/AAP10things-march2014.pdf  ). nothing very surprising. 1. not use antibiotics for apparent viral infection (sinusitis, pharyngitis, bronchitis) -- still used too much, though rates have fallen 2. not give cough/cold remedies to kids under 4 3. not do CT for minor head injuries. clinical observation often sufficient and less radiation. 4. not do neuroimaging in kid with simple febrile seizure 5. not routinely do abdominal CT in kids with abdominal pain (again, too much radiation and often risks>benefits) 6. no advantage to high dose steroids for prevention/treatment of bronchopulmonary dysplasia in premies 7. not order IgE screening panels for food allergies without reasonable medical history (too many false positives: eg, 8% of population test positive for peanut allergy, but 1% are really allerg

Studies have shown that older patients with diabetes and hypertension (and hyperlipidemia, to a lesser degree) have increased likelihood of cognitive impairment as well as brain atrophy (also a predictor of subsequent cognitive decline). As part of the ACCORD trial (RCT of 10K diabetic pts with prevalent CAD or lots of risk factors, treated with intensive vs less-intensive glucose control, as well as greater or lesser lipid and blood pressure control), the Memory in Diabetes (MIND) substudy also assessed cognitive and MRI outcome of total brain volume (TBV) (see  htn tight control DM inc cognitive decline jama int med 2014  in dropbox, or doi:10.1001/jamainternmed.2013.13656). Cognitive assessment was for psychomotor function and speed of learning/working memory  ( Digit Symbol Substitution Test) , verbal memory and executive function (Rey Auditory Verbal Learning Test and Stroop Color-Word Test) and Mini-Mental Status Exam. 2977 participants without baseline cognitive impairment and

the  Scandinavian  prostate cancer group study just published their 18 year followup of radical prostatectomy vs watchful waiting in men with localized prostate cancer (study prior to PSA testing, and was largely of men with palpable nodules).  see   prostate ca  scandan  18 yrs  nejm  2014  in  dropbox , or  DOI : 10.1056/ NEJMoa1311593. this follows their 15 year followup published a couple of years ago. in brief,     --695 men with early prostate cancer randomized to surgery vs watchful waiting, followed up to  23.2 years, though overall analysis at 18 year mark:         -- 63 deaths from prostate cancer in surgery group and 99 in watchful waiting (18% vs 29%, RR 0.56), absolute diff of 11% and NNT to prevent one death = 8     --200 deaths from all causes in the surgery group and 247 in the watchful waiting group (56.1% vs 68.9%, RR 0.71, abs diff 12.8%)      --androgen-deprivation therapy in fewer pts in surgery group vs  watchful waiting , (42.5 vs 67.4%, abs diff 25%)

new guidelines just came out from the CDC on screening for  chlamydia  and gonorrhea, with a few significant changes (see  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6302a1.htm?s_cid=rr6302a1_x  ). although there is no clear gold standard test for either Chlamydia or gonorrhea, nucleic acid amplification tests ( NAATs ) are considered the most reliable.  Recommendations: --Sexually active women less than  26yo  as well as those older with risk factors (e.g., new sex partner, multiple partners) should be screened annually for  chlamydial  infection --For gonorrhea, there is wide difference in local epidemiology, and testing strategies should be adaptable.  In general targeted screening is indicated in women at high risk, since infections are so frequently asymptomatic. -- For screening in women, the vaginal swab is the preferred specimen type.   These are as sensitive as cervical swabs and there is no difference in specificity.  Self-collected vaginal swabs are of equal sensiti

review article in new england journal this week on management of skin abscesses in era of methicillin-resistant staph aureaus MRSA  (see  skin abscesses mrsa review nejm 201 4 in dropbox or  DOI: 10.1056/NEJMra1212788). both the incidence of skin abscesses overall and the % of MRSA have increased over time. a few comments:     --diagnostic accuracy is not great: eg, a study of 126 adults with cellulitis where ER MD felt abscess not evident, ultrasound found abscess in 50%     --treatment of abscess is primarily I&D     --there may be more rapid healing if the I&D incision is closed vs leaving it open (studies mostly in the anogenital area, showing half the healing time and no diff in recurrences). should consider primary closure if incision >2cm. [goes against conventional wisdom that needs to be open to continue draining]     --no data as to whether to irrigate the wound, and data on whether packing helps is unclear (a couple of very small studies done

BMJ online just published an article showing utility of delaying  antibiotics, or giving no antibiotics, in patients with upper resp infection ( link:  http://www.bmj.com/content/348/bmj.g1606.pdf%2Bhtml  ). in brief,     --889 pts over age 3 (median age 30) in 25 practices in UK were given advice about symptom control (antipyretics, +/- vaporizer) and then either immediate antibiotics in  333 (37%)   (the group felt to have more severe sx and felt more likely to have lower resp tract infection), and in 556 (63%) randomized to the following different strategies:             --having the patient subsequently recontact the clinic to request a prescription if needed -- pts told that symptoms typically worst on days 2-4             --post-dating the prescription             --having the patient come back to the clinic just for a prescription if needed             --given a prescription but asking the patient to wait to fill it             --no antibiotic prescribed     --r

editorial in NY times today about the cost of sofosbuvir, new highly effective oral medication for hepatitis c (see  http://www.nytimes.com/2014/03/16/opinion/sunday/how-much-should-hepatitis-c-treatment-cost.html?ref=todayspaper ). a few points:     --150 million people infected worldwide     --typical 12-week course costs $84K ( that is, $1000/pill). this translates to $18 billion for one year treatment in california alone     --pricing is based not on costs (R&D), but Gilead's assessment of costs of other therapies (which they seem to overstate) and expected savings since the drug is so great (also questionable)     --prices in the US are much higher than in Europe or other countries. it is a great drug. but the cost may make it inaccessible to lots of people (some insurors not cover), or increase overall costs of health care (which is passed on to the govt and all of us), or limiting access to particular groups with perhaps more advanced disease (may be assoc w

NY times reports unanimous vote by FDA subcommittee to replace pap smears with HPV testing alone. prior to this being a new policy, has to be approved by FDA (which almost always happens), though many providers may not use this test alone unless approved by professional societies. the initial test would be done at age 25. for full article:  http://www.nytimes.com/2014/03/13/health/an-fda-panel-recommends-a-possible-replacement-for-the-pap-test.html?_r=0   of note,      --approx cost (in houstin texas): $50 for pap, $150 for HPV     --only one of the hpv tests, the one by roche (not the most common one done), is approved     --the current guidelines (pap age 21-30 q3yrs, then combo pap/HPV after age 30 q5yrs), have consciously postponed hpv screening til age 30 because in younger sexually active women, these infections most often regress spontaneously and, if picked up by screening, could lead unnecessarily to more invasive followup procedures (eg culposcopy and maybe more).

MMWR came out today with very likely case of female-to-female transmission of HIV, although it is apparently a quite rare form of transmission (see  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6310a1.htm?s_cid=mm6310a1_e  ). basically, one of the women had known HIV and stopped taking antiretrovirals in 2010.  there was a 6-month monogamous relationship between this woman and an HIV-negative one. the woman who acquired the infection had no injection drug use, tattoos, acupuncture, and had 3 female sexual partners in prior 5 years. for $$, she sold her plasma and had tested HIV neg after donating in March 2012. 10 days later had sx of acute HIV, went to the ER and had neg HIV antibody screen (EIA) -- no viral load done. 18 days later, she went to sell plasma again but was positive by EIA for HIV ab and western blot. to confirm the likelihood of female-to-female transmission, genetic analysis was done on both viruses, the virus transmitted was virtually identical (>98% of HIV sequence