geoffrey modest medical blogs

the Infectious Diseases Society of America just updated their 2005 guidelines for treatment of skin and soft tissue infections (see  skin infections guidelines inf dis soc of am 2014  in dropbox, or doi:  10.1093/cid/ciu296). the guideline deals with minor infections and up to life threatening ones, but i will focus on ones seen/treated in primary care (there is also an algorithm for wound infections, which i will leave to you to investigate). - -mild nonpurulent infections (cellulitis, erysipelas)  -- where mild infection is defined as skin infection without systemic signs of infection (>38 deg C, tachycardia >90, tachypnea >24,or WBC >12K or <400, or immunocompromized):     --blood culture/biopsies etc only if pt immunocompromized (and these patients should be admitted/get IV antibiotics)     --should use antibiotic with anti-strep activity for 5 days, then extend if necessary ...

the Agency for Healthcare Research and Quality (AHRQ) just published a technical brief (though, in reality, it is 51 pages long...)  on "decision aids for advance care planning".  see http://www.effectivehealthcare.ahrq.gov/ehc/products/550/1938/advance-care-decision-aids-report-140729.pdf  for the report. perhaps the most useful part of it is a review of the ACP (ie, Advanced Care Planning) tools available on the web with the specific content of the different ones, including ones that are secure, legal, and free (their Table 3a), with a special table for those with serious/advanced illness (Table 3a), and a review of the literature on the effectiveness of these aids as well as a table summarizing their evaluation of them (Table 6).

just bringing up this issue to make sure we are aware of the potential for hepatitis E infection, with recent study highlighting blood product transmission of hep E in the UK (see  hep e in UK lancet 2014​  in dropbox, or doi:10.1016/S0140-6736(14)61034-5). background:      --hepatitis E is an RNA virus similar to hep A (first identified in 1978 as a water-borne, enterically transmitted non-A, non-B viral hepatitis, found to cause an epidemic outbreak in Kashmir). currently second most common cause of sporadic hepatitis in North Africa and Middle East, and with huge outbreak (>100K people) in China in the 1980's. spread largely by fecally-contaminated water. documented transmission in japan, germany, france by eating undercooked pork (and deer, boar) and likely can be perinatally transmitted. 3rd NHANES study (1988-94)  in the US found strikingly high hep E seroprevalence at 21%!! , esp in those with pets or who co...

the BMJ's last issue had 6 articles on dabigatran (Pradaxa), showing the malfeasance of the drug company in promoting this agent [dabigatran is a direct thrombin inhibitor, specifically marketed as a competitor of warfarin for nonvalvular atrial fibrillation, though promoted for other indications as well, with the specific selling points based on a single key trial (RE-LY, see critique below) finding slightly lower incidence of major bleeding (16.4% vs 18.15%) without the costly and inconvenient monitoring of INRs required for warfarin -- ie, the high cost of the drug was more than justified by the savings from office visits and laboratory monitoring for warfarin. the American Heart Association's atrial fibrillation guidelines that I sent out recently endorsed direct thrombin inhibitors, as has European and Canadian guidelines (eg Natl Institute for Health Care Excellence in UK, or NICE). the following issues were discovered from the drug maker (Boehringer Ingelheim), largely...

The International AIDS Society-USA  just published guidelines regarding hiv treatment (see  hiv antiretrov rx recs 2014 jama ​ in dropbox, or doi:10.1001/jama.2014.8722). recommendations (lots of changes since 2012): When to start therapy :     ​-- Begin ART as soon as diagnosed HIV and independent of CD4 count , though recommendations more emphatic for those with CD4<500, or if pregnant, chronic hep B coinfection, HIV-associated nephropathy). should also be offered in acute infection, regardless of symptoms     --Begin ART within 2 weeks of diagnosis of opportunistic infections (OI) and other AIDS-defining illnesses (eg lymphomas, HPV-related cancers)     ​--for cryptococcal infections, optimal timing may be after 5 weeks of anti-cryptococcal infection [data are a bit mixed. in COAT trial there was increased mortality in those with severe disease, CD4<50 and CSF WBC<5 who were...

The International AIDS Society-USA  just published guidelines regarding hiv prevention (see  hiv prevention  guidelines 2014 jama  in dropbox, or doi:10.1001/jama.2014.7999). recommendations: Testing:     --all adults and adolescents should be offered HIV screening at least once [of note, we have found an HIV- positive Cape Verdean couple >70yo in our clinic...]     --evaluate risk periodically to determine if more frequent testing is warranted     --testing with informed consent, according to individual patient's needs (ie tailored, not  formulaic approach...). should (obviously) honor patient's right-to-refuse testing, but this should be  documented     --use rapid testing, esp in patients less likely to return for their results     --consider home testing for those with recurrent risks, difficulty in...

sometimes it is nice to have a study reaffirming one of the (many) obstacles to delivering high-quality medical care, minimizing medication errors.  The annals of internal medicine just had a study confirming the high rate of errors associated with prescribing generic drugs with ever-changing colors, sizes, shapes...  (see  medication errors with generics ann intern med 2014  in dropbox, or doi:10.7326/M13-2381).  the issue here, which i see almost on a daily basis, is that the patient goes to the pharmacy, gets a refill on a medication, sees it looks totally different from their prior pill, stops taking it because of fear that the new pill was given in error, then comes to me (and i often have to take the time from a busy primary care session to call the pharmacy to make sure it in fact was not an error). obviously, this takes a lot of time, creates angst in the patient, and poses a risk of adverse events by patients not taking their needed medicatio...

industry-sponsored study in the lancet of a new dengue vaccine (see  dengue vaccine lancet 2014  or  doi.org /10.1016/ S0140 -6736(14)61060-6). background (in brief):          --50 million infections/year in 100 countries (though some report 390 million cases/yr with 96 million having clinical disease), now including florida and texas areas     --mosquito vector (aedes aegypti and a. albopictus). spread of disease associated with globalization (transport of mosquito vectors as well as infected people), urban crowding, ineffective mosquito control strategies, and (likely) global warming.      --4 serotypes (types 1-4). these are present in all regions, with changing frequency of the different serotypes within the same country lancet study:     --phase 3 trial of vaccine efficacy. RCT in 5 countries in Asia-Pacific region (indonesia, malaysi...