geoffrey modest medical blogs

This is the second of the smoking-related emails, a provocative perspective appeared in the journal Addiction arguing for easier access to vaporized nicotine products ( VNPs ) as a means of harm reduction for smoking ( see  smoking cessation  ecigs   addiction2016 ​ in  dropbox , or  doi:10.1111 / add.13394 ​ ). their lines of argument (which does include some mathematical modeling to assess the potential long-term outcomes of these pretty new devices): --a multi-criteria decision analysis estimated that exclusive  VNP  use would be associated with about 5% of smoking's mortality risk (and is similar to low-nitrosamine smokeless tobacco). --studies looking at cancer biomarkers suggest an even lower risk for cancer, 9-450 times lower than cigarette smoking --so, the crux of the decision analysis of benefits of  VNPs  really relies on whether  VNPs  do lead to cigarette smoking in those not having smoked before, whether their use is helpful in smoking cessation, and if their

A couple of recent articles dealt with issues of smoking cessation (will send out one tomorrow) : 1. the lancet had a study finding finding no significant increase in psychiatric risk with any of the smoking cessation medications (see  smoking cessation neuropsych bup varen lancet2016  in dropbox, or doi.org/10.1016/S0140-6736(16)30272-0 ).  the FDA had issued an early warning on neuropsych concerns with varenicline, later extended to bupropion, based on case reports, and issued a post-marketing requirement for makers of both drugs to do RCTs to assess these risks. hence this drug-company sponsored study.  details: --8144 smokers smoking at least 10 cigarettes/d in the past year, 4116 having underlying psych disorders/4028 in the non-psych cohort. in terms of the cohorts:     --nonpsych cohort: mean age 46, 50% female, 83% white/13% black, wt 80 kg, 47% US/33% western europe/11% eastern europe/10% central/south america, Fagertstrom Test for Cigarette Dependence (FTCD) score

Subgroup analysis of the PROMISE trial found a significant difference in prognostic information in women vs men by the type of cardiac test done (see  cad testing men vs women  jacc2016 ​ in dropbox , or  DOI : 10.1016/ j.jacc.2016.03.523 ).  for my review of the PROMISE trial overall, see  http://gmodestmedblogs.blogspot.com/2015/03/coronary-angiography-or-exercise_17.html    , which includes my concerns about radiation exposure as well as what what defines the gold standard to evaluate sensitivity/specificity. details: --in the original PROMISE trial, 10,003 outpatients with stable symptoms suggestive of CAD were randomized to a functional test (a stress test, as chosen by the clinician: exercise  ECG , stress echo, or stress nuclear) vs anatomic test (computed tomographic angiography - CTA), followed 25 months, and investigators found no difference in outcomes. the current analysis looked at the prognostic capabilities of the different non-invasive tests by sex. --8966 patien

the Agency for Healthcare Research and Quality (AHRQ)  just published an update on diabetes meds for adults with type 2 DM, looking at some of the newer studies on the meds (see  https://www.effectivehealthcare.ahrq.gov/ehc/products/607/2215/diabetes-update-2016-report.pdf ​ , also published in annals of internal medicine at  doi:10.7326/M15-2650  ).  they assessed 4 key questions (KQs). findings (which limited in many cases by lack of reasonable studies): KQ 1. comparative effectiveness of monotherapies for A1c, weight, systolic BP (SBP), and heart rate; and in particular for metformin-based combinations --for reducing A1c:     --metformin, thiazolidinediones (TZDs) and sulfonylureas (SU) were best. DPP-4 inhibitors less good     --combos of metformin plus TZD, SU, SGLT-2 inhibitors and DPP-4 inhibitors were generally better in lowering A1c than metformin alone. (best were metformin plus SU or TZD). not enough data for GLP-1 receptor agonists --for reducing weight: