geoffrey modest medical blogs

an Israeli study was just published in which adults with type 2 diabetes were randomized to drinking wine vs water, and an array of cardiometabolic  parameters were assessed (see  alcohol intake diabetes AIM2015  in dropbox, or Ann Intern Med. 2015;163:569-579​) -- the CASCADE trial: CArdiovaSCulAr Diabetes & Ethanol trial, which just goes to show you that you can develop an acronym pretty easily for just about anything. details: --224 patients (baseline: mean age 60, 69% men, BMI 30.0, HDL 1.12 mmol/L or 43.5 mg/dL, LDL 2.41 mmol/L or 93.0 mg/dL, cholesterol/HDL ratio 4.1, fasting plasma glucose 150.4 mg/dL or 8.3 mmol/L, HgbA1C=6.9%, BP 137/78, waist circumference 105 cm, and mean positive metabolic syndrome criteria was 3.1 of 5) were randomly assigned to 150ml of mineral water, white wine or red wine with dinner daily for 2 years. Previously, these subjects had drunk no more than 1 drink of alcohol/week (mean 2.3 g/d) --all fol...

Given the increasingly concerning issue of prescription opioid misuse, there was a disturbing article in Pediatrics finding that even appropriate use of prescription opiates in teenagers is associated with future opioid misuse (see   opioids in adolescents future misuse Peds 2015  in dropbox, or DOI: 10.1542/peds.2015-1364). details: --prospective data from nationally representative cohorts of 6,220 12th-graders, followed up through age 23, in the Monitoring the Future study. --initial survey data included questions on "legitimate" use of opioids, to see if the teens had ever taken narcotics because "a doctor told you to use them", as well as use of marijuana/cigarettes/non-medically prescribed opiates/barbituates/alcohol, whether they disapproved regular use of marijuana,  and some demographic and school performance questions. They also asked if in the last 12 months they had they on one or more occasions taken "narcoti...

the NY Times had a rather telling editorial 10/20/2015 about drug company shenanigans (see  http://www.nytimes.com/2015/10/20/business/drug-makers-sidestep-barriers-on-pricing.html?emc=edit_th_20151020&nl=todaysheadlines&nlid=67866768&_r=0  ). it turns out that there is a prescription drug on the market called "Duexis", which is a combination of ibuprofen and famotidine (both over-the-counter and cheap drugs) and costs $1500/month. Since insurers are hesitant to pay this amount for the drug, the drug company (Horizon Pharma) circumvents the issue by having a mail-order specialty pharmacy ("Prescriptions Made Easy") affiliated with the drug company simply mail the med to the patient and then deal with the insurance companies.  a few details: --Horizon has increased the price 10-fold since it was introduced in late 2011.   --Duexis has had a 72% increase in sales volume in the  first half of this year compared with first half of l...

A rather striking article came out recently finding early infancy microbiome changes are associated with increased risk of childhood asthma, further feeding my interest/concern with changes in the microbiome and disease ( see  asthma microbiome kids sci trans med 2015  in dropbox, or  Sci Transl Med 2015; 307 (Sept 30): 307ra152 ).  In humans, it seems pretty clear that there are genetic factors which predispose individuals to asthma/allergies, but the dramatic recent increase in incidence confirms an environmental component. The hypothesis is that early life events alter the microbiome, including such things as pre and peri-natal antibiotics, delivery by C-section, urban vs farm living, and formula feeding (see  http://gmodestmedblogs.blogspot.com/2014/06/asthma-and-early-exposure-to-allergens.html   for prior blog on this). Mouse and some human studies show that there is an early-life critical window when gut micro...

An article just came out comparing total knee replacement surgery (TKR) with nonsurgical management for knee osteoarthritis (OA) --see  knee arthritis TKR vs nonsurg NEJM 2015  in dropbox, or N Engl J Med 2015;373:1597​, along with an editorial ( N Engl J Med 2015;373:1668 ).  670,000 TKRs were done annually in the US in 2012  (with dramatic increase over time) and at a cost of $36.1 billion.  This is the first RCT comparing TKR  to nonsurgical management, and follows on the heels (?knees) of a study showing that arthroscopic surgery was no better than sham surgery or exercise, though had more adverse events ( see   http://gmodestmedblogs.blogspot.com/2015/06/arthroscopic-surgery-for-knee-oa-not-so.html    ). details of the study: --100 patients (62% female; mean 66 yo; BMI 32; Kellgren-Lawrence score of 4 in 46%, 3 in 42% -- and score of >=2 being definite OA and 4 being the most seve...

JAMA just published a randomized clinical trial on the use of opioids or cyclobenzaprine in addition to naproxen for patients going to the emergency room with acute low back pain ( see  LBP opioids JAMA2015  in dropbox, or JAMA. 2015;314(15):1572-1580​). details: --setting: inner city ER in the Bronx, New York City, looked at patients with nontraumatic, nonradicular low back pain (LBP) of <2 weeks' duration and had score >5 on Roland-Morris Disability Questionnaire (RMDQ), a 24-item instrument used to assess functional impairment in patients with LBP, with scores ranging from 0 to 24. a 5-point improvement is considered clinically significant --323 patients (mean age 39, 50% men, 45% never had LBP before and 12% had it >1x/year, 28% had on-the-job injury, 5% positive depression screen, and mean RMDQ was 20) were randomized to naproxen 500 bid, along with either placebo, cyclobenzaprine 5mg , or oxycodone/acetaminophen 5/325 mg (all...

There have been 3 recent  JAMA  articles suggesting lack of efficacy of physical therapy in several settings. 1. in  patients with acute low back pain (see  low back pain and early PT  JAMA2015  in dropbox , or  JAMA .   2015;314(14):1459-1467). details: ​--220 patients without low back pain (LBP) treatment for past 6 months: median age 37, Oswestry  Disability Index ( ODI , a validated 10-item measure of function) of >=20, symptom duration <16 days and no symptoms distal to the knee in past 72 hours. --randomized to early PT (spinal manipulation and exercise) with 4 PT sessions over 3 weeks, beginning within 72 hours of enrollment vs no additional interventions for 4 weeks (all participants were given a copy of The Back Book, which was reviewed with them). outcomes assessed at 1 year. --results:     --PT better than usual care at 3 month ( ODI  score decreased from 41.3 t...