geoffrey modest medical blogs

The Annals of Intl Medicine just published an article on the relationship between visit-to-visit variability of blood pressure and coronary heart disease (CHD), stroke, heart failure and mortality (see  bp variability and chd annals 2015   in  dropbox , or   doi:10.7326 / M14 -2803). This was a post hoc analysis of the large database from the ALLHAT study (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial).  ALLHAT was an NIH and NHLBI funded study, and one of the best studies from a primary care perspective in that it really was community-based, with 623 clinical sites in the US, and included a truly ethnically diverse population (45% non-Hispanic white, 30% non-Hispanic black, 15% Hispanic white and 3% Hispanic black) to look at the effects of antihypertensives (one of its wings) in adults >55 yo with at least one CHD risk factor. details: --25814 patients with at least 7 visits during the study, noting the visit-to-visit variability (VVV) of blood p

a 5-year study from Australia (the LEGACY study, Long-term Effect of Goal directed weight management on Atrial fibrillation Cohort) looked at a cohort of people with atrial fibrillation (paroxysmal or persistent) to assess the relationship between weight loss, weight fluctuations and atrial fibrillation (see  afib and weight loss JACC 2015  in dropbox, or  doi.org /10.1016/j.jacc.2015.03.002 ). details: --355 patients with atrial fibrillation (AF) and BMI ≥  27 kg/m2 (mean age 65, 64% male,   weight  100 kg , BMI 33, 53% with paroxysmal AF, 80% hypertensive, 30% diabetic, 30% drinking >30g alcohol/week) were offered weight management         ​--face-to-face counseling, with 3-monthly evaluation. meals were high protein/low glycemic index and calorie-controlled.  if patient lost <3% of weight after 3 months, they received very-low-calorie meal replacement sachets for 1-2 meals/day. also, there was an exercise component, increasing to 300 min of moderate-intensity activity/w

​an array of recent articles highlighted the issue of antibiotic overuse (and the increasing potential for antibiotic resistance). background -- t he CDC in 2013 released a report elaborating the burden of antibiotic resistance:  2 million antibiotic-resistant illnesses and 23,000 deaths yearly in the US. 1.  CDC researchers published  a study looking at outpatient prescriptions dispensed in 2011, using the IMS Health Xponent database which contains >70% of all outpatient prescriptions in the US, including all payers from community pharmacies and nongovernmental mail service pharmacies (see  antibiotic overprescribing cid 2015 , or Clinical Infectious Diseases 2015;60(9):1308–16). >60% of antibiotic expenditures are in the outpatient setting. 58% of all antibiotic prescriptions in the outpatient setting are for respiratory infections that are predominantly viral.  a total of 262.5 million courses of outpatient antibiotics were prescribed in 2011, an astounding 842 prescripti

A recent study assessed the accuracy of the 2013 ACC/AHA guidelines in identifying patients in the Framingham Study who either developed cardiovascular disease (CVD) and/or coronary artery calcification (CAC), comparing the results to that of the prior 2004 ATPIII guidelines. (see  chol AHA guidelines fram study jama 2015  in dropbox, or JAMA. 2015;314(2):134-141​). details: --2435 statin-naive participants (mean age 51.3, 56% female, mean Framingham Risk Score -- FRS -- of 6.7%, mean LDL 121 mg/dL, mean CAC score of 95 with 42% having CAC score >0, overwhelmingly white population) were enrolled from the longitudinal offspring and third-generation cohorts of the Framingham Study. median followup 9.4 years. results:         --39% of patients were deemed statin-eligible by the 2013 guidelines vs 14% by ATPIII.         --there were 74 (3.0%) incident CVD events (40 nonfatal MIs, 31 nonfatal strokes, 3 fatal coronary artery disease/ CAD events).         --those statin-eligi

A  recent  large multinational  study (START trial: Strategic Timing of Antiretroviral Therapy) from 215 sites in 35 countries assessed the effect of randomizing patients with CD4 counts >500 to immediate antiretroviral therapy (ART) vs deferring therapy until the CD4 counts decreased to 350 or the development of AIDS or other condition requiring ART (eg pregnancy) -- see  hiv start therapy early NEJM 2015  in dropbox, or DOI: 10.1056/NEJMoa1506816. This study was funded by the National Institute of Allergy and Infectious Diseases and others. details: --4685 patients (median age 36, 27% women) followed 3.0 years. The trial was stopped early because of clear benefit in the interim analysis, and all patients were offered ART. 32.8% of the patients were from Europe/Israel, 25.1% from South America/Mexico, 21.3%  from Africa, 10.8% from North America, 7.6% from Asia. 55% of those developing HIV were MSM, 38% heterosexual contact, 1.4% injection drug use, 5.2% from blood products

A recent case-control analysis from the National Center on Birth Defects compared women who had children with birth defects to those without, to assess the association of the birth defects with specific SSRIs (selective serotonin reuptake inhibitors) taken from the month before  pregnancy and through the third month of pregnancy ​(see  depression ssri birth defects bmj2015  in dropbox, or  BMJ 2015;350:h3190​). details: --17952 mothers of infants with birth defects from US centers in 10 states were compared with 9857 who did not have infants with birth defects. they looked specifically at the birth defects previously reported to be associated with SSRIs, with data from the US National Birth Defects Prevention Study database. Excluded were mothers at higher risk for having children with birth defects for other reasons (diabetes, teratogenic drugs), or those not on SSRIs for psych conditions including depression, bipolar disorder, obsessive compulsive disorder. --researchers looke

the FDA just reinforced their existing warning label on the use of non-aspirin NSAIDs and the increased chance of heart attack or stroke (this warning is already on the over-the-counter ones). their comments: --the risk of heart attack or stroke can occur within the first weeks of taking NSAIDs --the risk is greater with higher doses --although they acknowledge that newer information suggests some differences in NSAID risk, they do not feel it is sufficient to attribute either higher or lower risk to any individual agent --the increased heart attack/stroke risk is not limited to those with known heart disease or increased risk factors form heart disease, though since their absolute risk is higher in general, they have greater risk of NSAID-induced heart attack or stroke --those with known heart disease or risk factors are even more likely to die of a heart attack or stroke in the first year after their heart attack --there is increased risk of heart failure with NSAIDs