geoffrey modest medical blogs

it is unclear from the literature what the goal blood pressure should be in patients with atrial fibrillation, and this is not addressed by any of the guidelines. A post hoc analysis of the AFFIRM trial (Atrial Fibrillation Follow-up Investigation of Rhythm Management, a prospective trial assessing the strategy of rate versus rhythm control) looked retroactively at the relationship of achieved blood pressure and outcomes (see  afib optimal bp amjcardiol2014 in dropbox, or Badheka AO. Am J Cardiol 2014; 114: 727)). Details: -- 3947 patients in the trial were followed 6 years, noting their systolic and diastolic blood pressures (recorded after sitting quietly for at least five minutes) at baseline and at follow-up, divided into 10-mm Hg increments. The follow-up blood pressure was defined as the average of all available blood pressure measurements during each post-baseline visit -- mean age 69, and the following were significantly (and much) more frequent in patients who had l

A recent article looked at the relationship between achieved LDL cholesterol levels and changes in coronary artery atherosclerosis progression, as determined by coronary CT angiography, CTA (see  lipids intensive LDL lowering dec CAD progression JACC2016 in dropbox, or doi.org/10.1016/j.jcmg.2016.04.013).  Details: -- 147 patients with evident atherosclerotic plaques on CTA had quantitative plaque size measured both at baseline and at follow-up CTA two years later (median 3.2 years) -- baseline characteristics: mean age 62, 57% male, 65% with hypertension, 33% diabetes, 20% active smoking, 27% dyslipidemia (defined as total cholesterol >240 mg/dL, LDL >130, HDL <40, triglycerides >150, and/or treatment with lipid-lowering agents), cardiac risk score by both the ATP III and Framingham risks:  60% low risk (<10% over 10 years),  30% intermediate (10 to 20%), and  10% high risk (>20%). Number risk factors = 1.6 -- multi-center, observational study, assessi

On 10/19/16, the CDC recommended that 9 to 14 year olds receive only 2 doses of the 9-valent HPV vaccine at least 6 months apart, instead of the prior recommendation for 3 doses.  But those who started the series between ages of 15 through 26 continue to need 3 shots (see http://www.cdc.gov/media/releases/2016/p1020-hpv-shots.html for the press release). Here is the article it was based on (see  hpv vaccine 2-dose jama2016  in dropbox, or doi:10.1001/jama.2016.17615). details: -- open-label, non-inferiority study done in 52 ambulatory sites in 15 countries, with 5 cohorts:                 -- girls aged 9 to 14, getting 2 doses 6 months apart (n= 301)                 -- boys aged 9 to 14, getting 2 doses 6 months apart (n= 301)                 -- girls and boys aged 9 to 14 getting 2 doses 12 months apart (n= 301)                 -- girls age 9 to 14 getting 3 doses over 6 months, the current recommendation (n= 301)                 -- adolescent girls and young wom

Two recent articles highlight increasing antibiotic resistance. 1. Neisseria  Meningitides Meningococcus is becoming increasingly resistant to third-generation cephalosporins (see  meningococcal resistance to cephalosporins jantimicchemo2016 in dropbox , or doi:10.1093/ jac /dkw400). Details: -- There are approx 500 cases annually of invasive culture-confirmed meningococcal disease in France, and about 76% of the samples go to the  French National Reference Center for Meningococci for evaluation -- in 2012, of 357 invasive meningococcal isolates, 27% had a significant increase in their MICs (mean inhibitory concentrations) for penicillin G (increasing from 0.125 to 0.5 mg/L), though they still had low MICs for cefotaxime. -- From 2012-15, 7% of these meningococcal isolates (25 of them) had higher penicillin G MICs (2% of all isolates), harboring a new allele (penA327), which was increasingly detected over this date range and not seen before 2012 -- this a

there have been several concerning issues and lessons that I have learned in the process of doing these blogs over the past several years (I am sending out this email/blog as a followup to some of the methodological issues and perhaps incorrect assumptions inherent in many clinical studies and their application to actual patients, as noted in the recent blog on placebos. see email of 11/14/26, entitled: " Benefits of placebo for low back pain, and some random thoughts" ). -- meta-analyses :     --there is huge variability in the actual utility of meta-analyses in making clinical decisions. these analyses are mathematical concoctions which try to combine different studies with usually very different people (different inclusion/exclusion criteria, people with different levels/types of comorbidites, different ages, different ethnicities, often different doses of the med being assessed, even somewhat different outcomes measured). and the meta-analyses themselves have dif

Most of us, I believe, usually prescribe generic medications to patients, especially for patients who have limited or no insurance and have large out-of-pocket medication costs. A recent study looked at the variability of 3 generic drugs used for heart failure finding dramatic differences within similar geographical areas (see generic drug cost variability jamaintmed2016 in dropbox, or doi:10.1001/jamainternmed.2016.6955). Details: -- data reflect 153 chain and 22 independent pharmacies in a 2-state region (Missouri and Illinois), across 55 zipcodes -- they compared the cost for uninsured patients of low and high dose digoxin (0.125 and 0.25 mg/d), lisinopril (10 and 40 mg/d), and carvedilol (6.25 and 25 mg bid) for 30– and 90–day supplies. -- They also correlated the costs with the annual income by zipcode results: -- median annual income within pharmacy zipcode s was $53,122, with a range of $10,491 – $112,017 -- the number of manufacturers was about 8 for ea

A recent study looked at the relative effects of genetic risk and healthy lifestyle in the development of coronary artery disease (see  cad genetic risk dec CAD with lifestyle change NEJM2016 in dropbox, or DOI: 10.1056/NEJMoa1605086​). Details: -- 3 prospective cohorts were followed: the Atherosclerosis Risk In Communities (ARIC, with 7814 white people between the ages of 45 and 64), the Woman's Genome Health Study (WGHS, with 21222 white female health professionals), and the Malmo Diet and Cancer Study (MDCS, with 22389 Swedish people aged 44 to 73 and free from prevalent cardiac disease). Also included were 4260 people the cross-sectional BioImage Study who had genetic/risk factor data and had coronary artery calcium (CAC) scores -- they evaluated these people for up to 50 single–nucleotide polymorphisms (SNPs) known to be associated with coronary artery disease, and then derived a polygenic risk score based on the number of risk alleles at each SNP, multiplied by the su

The American Heart Association just published their recommendations for managing drug-drug interactions between statins and other drugs used for cardiovascular disease (see statin drug interactions circ2016 in dropbox, or DOI: 10.1161/CIR.0000000000000456 ). I bring this up because statins are such an important drug that we use all the time, drug-drug interactions overall are common (leading to about 3% of hospital admissions, and the result of many annoying flags in electronic medical records) and because this review goes into detail on the mechanisms of these interactions (whether through the cytochrome P-450, CYP450, system of oxidative enzymes, or those interactions involving permeability glycoprotein P-gp, a superfamily of membrane-associated ATP-binding cassette-transporters, also called multidrug resistance-1; this article gives a good review of these systems, the latter of which was pretty much unknown to me prior to seeing this article….), and the article comments on the li