geoffrey modest medical blogs

 a new study looked at 323K children in the US (from the Vaccine Safety Datalink) born between 2004 and 2008, assessing the timing of the array of first doses of childhood vaccines  and the development of seizures, with self-control -- ie, noting the timing of seizure after vaccination in children who never had a prior seizure (see  vaccine MMR delay and sz peds 2014  in dropbox, or DOI: 10.1542/peds.2013-3429).  the seizure risk window varied a bit by different vaccines, but was 7-10 days for MMR. results:     --5667 children had seizures. of these 49.7% received the vaccines on-time in the first 2 years of life.     --in the first year of life, no diff in seizures with vaccine timing (includes DTaP, PCV, HIB, IPV, rotavirus)     --in the second year of life, the IRR (incidence rate ratio) for seizures after the first MMR given at the recommended 12-15 months was 2.65. if given between 16-23 months it was 6.53!!  in those given the combo vaccine or MMR plus varicella, the IRR

I have had 2 Cape Verdean patients over the past few years who have developed gastric cancer.  Several months ago I met with a Cape Verdean doctor who confirmed that gastric cancer was relatively common in Cape Verde.  Gastric cancer screening in general does not make sense in the United States given the low prevalence of gastric cancer.  However, many of our patients come from countries with much higher prevalence, prompting this review.  I am sending this out  generally because many of us see patients coming from high prevalence countries.   Most of the data is not great.  There has been mass population screening in Japan since 1983  for individuals over 40, where gastric cancer is the leading cause of cancer death.  A systematic review was done by the Japanese Health Ministry (see   gastric ca screening japan 2008   in dropbox, or   doi:10.1093/jjco/hyn017 ) , which only   found   10   studies directly related to screening , none of which were randomized controlled trials   --

world health org just came out with report on antimicrobial resistance (see  antimicrobial resistance WHO 2014  in dropbox for summary, or URL:  http://apps.who.int/iris/ bitstream/10665/112647/1/WHO_ HSE_PED_AIP_2014.2_eng.pdf  ). remarkably scary report. their findings: --very high levels of resistance in all WHO regions for many common bacteria. eg (with 20-50% of the 194 member states providing data):     --e coli with >50% resistance both to 3rd generation cephalosporins and to fluoroquinolones  in 5/6 WHO regions     --klebsiella pneumoniae with   >50% resistance to 3rd generation cephalosporins in 6/6 regions and to carbapenems  in 2/6 WHO regions     --staph aureus with >50% resistance to methicillin in 5/6 regions     --strep pneumoniae with >25% resistance to penicillin in 6/6 regions     --nontyphoidal salmonella with >25% resistance to fluoroquinolones in 3/6 regions     --n gonorrhea with >25% resistance to 3rd generation cephalosporins i

there have been a couple of articles recently dealing with c. diff infections. 1. recent one from Mass General Hosp on use of fecal microbiota transplant (FMT) in patients with relapsing c diff infections (see  cdiff fecal tx clin inf dz 201 4 in dropbox, or DOI: 10.1093/cid/ciu135). the problem is that standard medical therapy (metronidazole or vanco) leads to recurrent c diff in 30% treated for a first episode. and, if 2 or more recurrences, there are diminishing returns: >60% have relapses. in this study, the fecal transplant was from screened, healthy volunteers, frozen and administered to 20 patients either through a nasogastric tube (10 patients) or colonoscope (10 patients). primary endpoint was resolution of diarrhea without relapse after 8 weeks. also looked at patient-reported health score. not an RCT (no placebo group). results:     --baseline: patients (average age 50) with median of 4 relapses (5 antibiotic treatment failures) --[ie, even without control group,

many of us have patients on large doses of opioids for chronic pain. there are an array of forces pushing us to decrease use of these drugs (the increase in prescription opioid drug-related deaths, the diversion of drugs leading to hospitalization and deaths of others, the increased surveillance by professional societies, insurors, etc). today in the NY times there was a long story of war veterans with severe injuries who got off opioids. not much detail on their support programs, but comments that they actually felt better of the opioids. also comment that 5 years ago, 80% of injured soldiers treated at walter reed hosp in washington were put on opioids. figure now is 10%, with comment that "many patients are benefiting from the change".   see  http://www.nytimes.com/2014/05/11/business/a-soldiers-war-on-pain.html?hp  

new data from CDC on US syphilis rates, which bottomed out in 2000 at 2.1/100K people, but in 2013 rose to 5.3/100K -- as in: more than doubled!! (see  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6318a4.htm?s_cid=mm6318a4_e ). in 2005, database included sex of sex partners, and found that in "2005-2013, primary and secondary syphilis rates increased among men of all ages and races/ethnicities cross all regions of the United States. Recent years have shown an accelerated increase in the number of cases, with the largest increases occurring among MSM." in women rates increased during 2005-8, then decreased 2009-13   (from 0.9/100K in 2005 to 1.5/100K in 2008 then back to 0.9/100K in 2013) . in the time period 2005-2013, overall annual rate almost doubled from 2.9 to 5.3 cases/100K people, with increasing male representation -- up to 91.1% of all cases in 2013. rate in black men was 5.2x that of white men (27.9 vs 5.4 cases/100K) and black women had 13.3x the rate of white women

probably the most exciting new drug for lipids are the PCSK9 inhibitors. i have appended below a blog from march 2012 which discusses proposed mechanism of action of these inhibitors as well as an epidemiologic study showing that those with naturally occurring PCSK9 function loss had much lower LDL levels and many fewer  coronary events. this new multicenter, multi-country study is the longest RCT to look at evolocumab, a monoclonal antibody that inhibits PCSK9, to assess its safety and efficacy (see  lipids PCSK9 evolocumab dec LDL nejm 2014  in dropbox, or DOI: 10.1056/NEJMoa131622). 901 hyperlipidemic patients per ATPIII were put on several different meds/combos for 4-12 weeks, then randomization of those with CAD and LDL<100, or those without CAD but high risk if LDL<130 to either 420mg of evolocumab (subq injection) or placebo every 4 weeks.     --baseline characteristics: mean age 56, 47% male, 80% white, mean LDL 95-120, results after 52 weeks, as compared to placeb

another article came out of the PREDIMED study (prevention with mediterranean diet study), where 6705 people without prevalent afib were randomly assigned to one of 3 diets: mediterranean diet supplemented with extra-virgin olive oil, mediterranean diet plus mixed nuts, or control group (low fat diet). in this post-hoc analysis they looked at the development of atrial fibrillation (see   afib olive oil dec risk circ 2014   in dropbox, or DOI: 10.1161/CIRCULATIONAHA.113.006921). [i sent out blog on 1/9/14 on primary CAD prevention and one on 1/8/14 on diabetes prevention from this study -- i appended excerpts below since they give details of diet]. the findings in the current study were:     --new cases of afib, after 4.7 years:         --med diet with supplemented extra-virgin olive oil: 72 cases, afib rate of 6.8 per 1000 person-years (and, there was a dose-response curve with higher olive oil consumption=less afib)         --med diet with supplemented mixed nuts: 82 cases, a

FDA with consumer statement about aspirin for primary prevention of heart disease.  they comment:   Use of Aspirin for Primary Prevention of Heart Attack and Stroke [05/02/2014] Cardiovascular disease, including heart disease and stroke, affects tens of millions of people in the United States.  Consumers and patients who do not suffer from cardiovascular disease sometimes consider taking aspirin to reduce the possibility of having a heart attack or stroke.  Reducing the possibility of having a first heart attack or stroke is called primary prevention.  The FDA has reviewed the available data and does not believe the evidence supports the general use of aspirin for primary prevention of a heart attack or stroke.  In fact, there are serious risks associated with the use of aspirin, including increased risk of bleeding in the stomach and brain, in situations where the benefit of aspirin for primary prevention has not been established. The available evidence supports the use of as

Vesicoureteral reflux is common in kids, is present in the third of children with febrile UTIs, and is associated with increased risk of renal scarring.  Studies have found mixed results on the efficacy of prophylactic antibiotics.  New England Journal with recent article -- a two-year randomized control trial in 607 children with vesicoureteral reflux diagnosed after a first or second febrile or symptomatic UTI, randomized to trimethoprim-sulfamethoxazole prophylaxis (3 mg trimethoprim, 15 mg sulfamethoxazole per kg of body weight) or placebo.  Primary outcome was preventing recurrent infections.  Secondary outcome was assessment of renal scarring, treatment failure (a composite of recurrences and scarring) and antimicrobial resistance (see  vesicoureteral reflux abx in kids nejm 2014  in dropbox, or DOI: 10.1056/NEJMoa1401811).  All urines were collected by catheterization or suprapubic aspiration.  Renal scanning was done at baseline and after 1 and 2 years.  Results:          

there has been ongoing speculation that there is a bacterial cause of ulcerative colitis (UC). Fusobacterium varium, in a prior study by the same researchers below, was found in actively inflamed colonic mucosa of patients with UC. (also, in mice, butyric acid, a byproduct of F. varium, causes UC-like lesions). so, this group devised an antibiotic cocktail active against F. varium (tid regimen of amoxacillin 500mg, tetracycline 500mg, and metronidazole 250mg for 2 weeks) and assessed its efficacy both in 30 patients with steroid-refractory and 64 patients with steroid-dependent active UC ( see   ulcerative colitis and antibiotics aliment pharm 2014   in dropbox, or doi:10.1111/apt.12688) .  primary endpoint was clinical response at 3 months after treatment completion. secondary endpoints were significant clinical and endoscopic score improvement at 12 months. results:     --Japanese multi-center non-randomized study. mean age 40. in steroid-dependent group, 45 males/19 females. pr

update on 2011 guidelines on stroke prevention in patients with prior stroke or TIA (see  stroke secondary prevention guidelines stroke 2014  in dropbox, or DOI: 10.1161/STR.0000000000000024) background: stroke still very prevalent. 700K adults with ischemic stroke/yr in the US. addl 240K with TIA (with residual high risk of subsequent stroke, 3-4%/yr, similar to having had initial ischemic stroke. rate is lower than before because of widespread use of antiplatelet drugs, treatment for hypertension, afib, hyperlipidemia, arterial obstruction). changes from 2011 (there are lots of them, and these are just the changes):     --hypertension.                   -- initiate therapy if systolic >140, or diastolic >90. no clear evidence that one class of drug is superior [though prior studies sent out before have found increased stroke in meds with higher b p variability,                      with amlodipine having the least].  uncertain benefit if initial blood pressure lo