geoffrey modest medical blogs

Older studies have shown an association between stress and peptic ulcer disease. At least the ones I've seen have not controlled for the use of NSAIDs or the presence of H pylori. However, from newer data, 16-31% of ulcers are not associated with either of these precipitating factors. The current prospective population-based study was done in Denmark, in which the researchers collected blood samples as well as an inventory of psychological, social, behavioral and medical data in 1982-3, and reinterviewed these patients in 1987-8 and 1993-4, finding that psychological stress did indeed increase the risk of ulcers (see  peptic ulcer dz and stress clin gastro 2014 in dropbox, or doi.org/10.1016/j.cgh.2014.07.052​). details: --3379 adults without prior history of ulcer disease were enrolled, with subsequent data on 2809 of them in 1987-8 and 2410 in 1993-4. Pretty evenly distributed in the 30-60 year age range. --socioecon...

Cytisine is a plant-based alkaloid, which is a partial agonist of nicotinic acetylcholine receptors (as with varenicline), and it has been used effectively for smoking cessation since the 1960s, largely in Eastern Europe. Historically, it has been well-tolerated with no overall increase in adverse events, though gastrointestinal symptoms are more common. It is a low cost intervention, $20-30 for 25 days (as opposed to nicotine replacement therapy -- NRT -- at $112-685 for 8-10 weeks, or varenicline at $474-501 for 12 weeks), though no trials had existed comparing efficacy of cytisine with nicotine replacement therapy. Hence, this New Zealand study (see  smoking cessation cytisine nejm 2014​ in dropbox, or N Engl J Med 2014;371:2353-62​), in which a 25 day therapy with cytisine is compared to 8 weeks of NRT, both with low-intensity behavioral support (basically, 3 calls of 10-15 minutes from Quitline advisors over 8 weeks). This was set up as a noninfe...

a recent short-term study of overweight individuals did not show a benefit for a low glycemic index (low GI) diet (see  low gi diet not help cv risk jama 2014 in dropbox, or JAMA. 2014;312(23):2531-2541​). in this randomized cross-over trial, overweight adults were given 4 different complete diets including all of their meals, snacks, and beverages, each for 5 weeks, with data below for those completing a minimum of 2 such diet rotations. details: --163 adults enrolled, mean age 53, 52% female, 51% black, 40% non-hispanic white, BMI 32 and waist circumference 104cm, 26% hypertensive, 16% smokers --diets (all based on DASH diet -- high in whole grains, fruits, veges, and lower in  low-fat dairy,   lean meats/fish/poultry and  nuts/seeds/legumes). all with similar amounts of potassium (4gm) , calcium (1 gm), sodium (2.3 gm), and all were 2000 kcal/day:     --high GI (65% on the glu...

one issue that comes up a lot is the transmissability of HIV in serodiscordant couples when the HIV-positive person has a suppressed viral load. a letter-to-the-editor was just published, reviewing 6 relevant studies (see  HIV transmission suppressed VL JAIDS 2014 in dropbox, or doi.org/10.1097/QAI.0000000000000471).  lacking the best data, the researchers assumed that a surrogate for suppressed viral load was if the  HIV-positive partner had been on combined antiretroviral treatment (cART) for >6 months (since usually the viral load is suppressed by then). they found: --at most one transmission in 113,480 sex acts, of which 17% were not condom-protected. --for that one transmission, data were not adequate to see if it happened before or after than 6-month mark --so, their estimation varies as follows:     --case 1: no transmission after 6 months -- upper bound of risk-per-sex act was 8.7 per 100,000    ...

the Lancet recently had a posthoc analysis of the ACCORD trial, finding that decreasing A1C in type 2 diabetics was associated with decreasing ischemic heart disease events (see  dm ACCORD intensive control dec CAD lancet 2014 in dropbox, or Lancet 2014; 384: 1936–41). This was one of 3 contemporary trials of intensive vs standard control of diabetics -- neither ADVANCE nor VADT studies showing benefit of intensive diabetic control for macrovascular complications, and ACCORD actually found an increase in mortality in the intensive group.  The trial: --10251 patients, mean age 62, with diabetes on average of 10 years, and all with high risk for heart disease and 35% with known CAD (coronary artery disease), and baseline A1C of 8.1% (this trial also had blood pressure and lipid trials embedded). no difference in # on statins (88%) or aspirin (76%). --intervention: keep adding meds to achieve an A1C of 6.0%...

there was a recent update of the CDC's "recommendations for HIV prevention with adults and adolescents with HIV in the United States" -- see  http://stacks.cdc.gov/view/cdc/26062 and you too can download the 240 page document...). the overall focus of this update  is to develop systems of care/infrastructure to facilitate improved access to and retention in care of HIV-positive patients. the underlying  issue is that recent studies have found that the vast majority of people with HIV are aware of their disease (around 85%, thanks to much more aggressive screening programs and, it seems to me, a broader acceptance of HIV in many communities), but only 2/3 are linked to care, 40% are retained in care, 1/3 prescribed antiretrovirals, and only 25% were effectively treated to suppress their HIV viral load (which has the dual benefit of, first, turning HIV infection from pretty much a death sentence into a chronic disease, and, second, vastl...

And another issue comes up with e-cigarette. Front page story in the New York Times on health hazards from contaminated e-cigarettes made in China (see  http://www.nytimes.com/2014/12/14/business/international/chinas-e-cigarette-boom-lacks-oversight-for-safety-.html?emc=edit_th_20141214&nl=todaysheadlines&nlid=67866768&_r=0 ​ ). 90% of the world's e-cigarettes are currently made in China, with expectations to export >300 million to the US and Europe this year. Although a New York Times review in Shenzhen found that many large factories were legitimate and did make efforts at quality control, there is no consistent regulation and some had no testing equipment. And some e-cigs are literally made in a garage and are knock-offs of established brands.  The result is that some fake e-cigarettes, which may even be mixed in with legitimate ones, may have hazardous metals from their inappropriate manufacturing process, with 25 or so different el...

A study from Missouri assessed the longterm outcome of a single corticosteroid injection for a trigger finger (see  trigger finger injection j bone surg 2014​ in dropbox, or J Bone Joint Surg Am 2014 Nov 19; 96:1849​). they assessed 366 patients who had a first injection and followed a minimum of 5 years.  background:      --trigger fingers are pretty common. lifetime risk estimated in general population of 2.6%, 4-10% in diabetics     --and, from my patients, pretty uncomfortable and affects daily functioning results: --66% female, average age 59 yo, 44% with multiple trigger fingers, 24% with diabetes.  majority had symptom of "catching" but able to actively extend the digit ​. --their protocol was injecting the A1 pulley area with methylprednisolone 40mg/cc, 1cc, and lidocaine without epinephrine 1%, 0.5 to 1 cc.  --primary outcome (which was to  n...

The AHRQ (agency for healthcare research and quality) came out with an evidence report/technology assessment for the diagnosis and treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome -- ME/CFS (see  http://www.effectivehealthcare.ahrq.gov/ehc/products/586/2004/chronic-fatigue-report-141209.pdf ​  ), reviewing 71 studies in 81 publications. findings: --in general, this diagnosis is entertained when there is chronic and disabling fatigue, along with a variety of other symptoms including neurological and cognitive changes, motor impairment, pain, sleep disturbance and altered immune and autonomic responses. The etiology is unknown: it is unclear whether ME and CFS are part of the same illness, or whether this is just a nonspecific set of symptoms shared by other disease entities. the diagnosis of ME/CFS requires exclusion of other possible diagnoses (eg, rheumatoid arthritis or other other immune diseases, etc) and there is considerable overlap with some p...

the US Preventive Services Task Force just published their recommendation for vitamin D screening: "the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults", which applies to community-dwelling, nonpregnant adults aged >18 yo seen in a primary care setting and without either signs/symptoms of vitamin D deficiency or conditions where vitamin D treatment is recommended (for review of recommendations, see  vit d uspstf recs 2014 in dropbox , or  or go to URL: http:// annals.org / article.aspx?articleid =1938935  ; for full systematic review, see  vit d uspstf systematic review 2014 in dropbox or either  http://annals.org/article.aspx?articleid=1938934   or http://www.uspreventiveservicestaskforce.org/Page/Document/EvidenceReportFinal/vitamin-d-deficiency-screening ​ ). this recommendation is largely based on the fact that no study has directly...

The FDA just came out with changes in labeling information regarding pregnancy and lactation on prescription drugs and biological products, replacing the old system of letter categories (A, B, C, D and X)​. These changes will go into effect June 30, 2015. in brief: --the "pregnancy" subsection will provide information on the use of the drug in pregnant women (eg, dosing and potential risks to the fetus), and whether there is a registry collecting data on how pregnant women are affected by the drug. --the "lactation" subsection will comment on the amount of drug in breast milk and potential effects on the breastfed child --the "females and males of  reproductive potential" subsection  will include comments on the drug's effect on pregnancy testing, contraception, and infertility --both the "pregnancy" and "lactation" subsections will include 3 subheadings: "risk summary", "clinical considerations" a...

so, what's wrong with this picture??? (see New York Times article:  http://www.nytimes.com/2014/12/08/business/paid-to-promote-eye-drug-and-prescribing-it-widely-.html?ref=business&_r=0 ). --Genentech came out with Lucentis, a new product in 2006 used by ophthalmologists to treat macular degeneration --It costs $2000/dose --it is "nearly equivalent" to Avastin and was approved only for this same indication. Several studies have concluded that "Lucentis has no significant advantage over its cheaper alternative" --Avastin costs $50/dose --Lucentis is one of Medicare's most expensive drugs, costing the federal government $1 billion in 2010 . Avastin was still much more commonly used, though Medicare spent only $27 million on it that year. In fact a study in 2011 showed that if all patients on Lucentis had received Avastin, the government would have saved $1.4 billion --and, many of the doctors "who were top billers for Lucenti...

In many areas, there is increasing H Pylori resistance to several antibiotics, including clarithromycin, with decreasing H Pylori eradication rates over time. A recent Korean study assessed the utility of selecting antimicrobial therapy based on antibiotic susceptibility vs standard clarithromycin-based triple therapy (see  hpylori rx resistance guided AJG 2014  in dropbox, or doi: 10.1038/ajg.2014.222). This issue is important because H pylori is so common, affecting about 50% of the global population (and in our experience, 80-90% of people from high risk countries), is an important risk factor for noncardiac gastric cancer, and there are significant data that H  Pylori elimination reduces the incidence of stomach cancers. in this study 112 patients with H Pylori and gastric epithelial neoplasia (adenoma and adenocarcinoma)  were randomized to a 7 day course of a proton pump inhibitor (PPI) such as pantoprazole 40mg bid, amo...

An analysis of the Nurses' Health Study found that those who ate more of a Mediterranean diet had longer telomeres, supporting the health and longevity results from this diet found in other trials (see  Mediterranean diet and longevity BMJ 2014 in dropbox, or BMJ 2014;349:g6674). Telomeres undergo attrition with somatic cell division, affecting their ability to prevent loss of genomic DNA at the ends of linear chromosomes, with shorter telomere length considered a biomarker of aging. This attrition is increased with oxidative stress and inflammation, so that age-related attrition rates varies considerably from individual to individual. The interest in this study is that the Mediterranean diet (one rich in vegetables, fruits, nuts, legumes, and unrefined grains; lots of olive oil but low intake of saturated lipids; lots of fish with less meat; and of course moderate intake of alcohol, esp wine at meals) is particularly antioxidant and anti-inflam...

The CDC just came out with final recommendations targeting provider counseling regarding male circumcision (see  circumcision cdc recommendations 2014​ in dropbox, no URL available at this time). the focus of these recommendations is to help with prevention of HIV, sexually transmitted infections (STIs), etc. They note the following: --the final decision about male circumcision is not only based on health considerations, but includes a variety of social, cultural, ethical and religious considerations --3 African studies (with very high baseline prevalence of HIV) have shown a 50-60% decreased risk of HIV transmission with circumcision of men engaged in penile-vaginal sex. additionally, there was a 30% decreased transmission of HSV-2 (herpes simplex virus type-2) and HPV (human papilloma virus). note: most new HIV infections in the US occur in men who have sex with men (MSM), for which there are no data that circumcision is effective. --their formal recommendations: ...

i ran across an article on the pathophysiology, diagnosis and treatment of excessive belching, which is a pretty common primary care issue, and i have mostly been treating it as a GERD symptom. but, of course, it is more complicated than that....  (see  belching AJG 2014 in dropbox, or Am J Gastroenterol 2014; 109:1196–1203​). it turns out that about 50% of the general population with dyspepsia report excessive belching. use of manometric testing/impedance monitoring has shown that there are 2 mechanisms: the "gastric belch", which is a vagally-mediated reflex with a relaxation of the LES (lower esophageal sphincter) and expulsion of gastric air, and a "supragastric belch"  in which pharyngeal air is sucked into the esophagus when the diaphragm contracts and causes a negative intrathoracic pressure, then is quickly expelled before it reaches the stomach through relaxation of the UES (upper esophageal sphincter) and a closed glottis. a few commen...

Both irritable bowel syndrome (IBS) and chronic idiopathic constipation (CIC) are very common (prevalence 5-20%) and without great medical therapies: "no therapy has been proven to alter the natural history of either condition in the long term". hence, the attraction of probiotics, which might alter the GI microbiome fundamentally. A recent meta-analysis looked at the use of probiotics (live or attenuated microorganisms that might be beneficial), prebiotics (food ingredients that remain undigested which might stimulate growth of beneficial microorganisms), and synbiotics (combinations of prebiotics and probiotics) -- see  irritable bowel probiotics AJG 2014 ​ in dropbox, or doi:10.1038/ajg.2014.202​. they reviewed 43 articles. there were 35 randomized controlled trials (RCTs) of probiotics, 2 of synbiotics and 1 of prebiotics for IBS.  for CIC there were only 3 of probiotics, 2 of synbiotics, and  1 of prebiotics....