geoffrey modest medical blogs

The second article on the ED evaluation of chest pain involved an instrument to predict/stratify cardiac risk, finding it to be quick, reliable and efficient (see  MI HEART score in ER AIM2017  in dropbox, or doi:10.7326/M16-1600). Details: --Nine Dutch hospitals assessed the HEART instrument prospectively to evaluate unselected patients presenting to EDs with chest pain, in a sequence where every 6 weeks, 1 hospital was randomly switched to using the instrument (see  MI HEART score in ER AIM2017  in dropbox, or doi:10.7326/M16-1600). Publicly-funded study. --3648 patients (1827 receiving usual care, 1821 HEART care) --Exclusion criteria included evident ST-segment elevation MI. --The HEART score is based on History, Electrocardiogram, Age, Risk Factors, and Troponin levels , with each having a score range of 0-2 (see  https://www.mdcalc.com/heart-score-major-cardiac-events  for HEART score calculator):    --score of 0-3 is low-risk, and the patient was to be discharged

Two articles recently came out in the Annals of Internal Medicine which looked at simple and efficient ways to rule out acute myocardial infarction in patients with chest pain who go to the emergency room. This blog will deal with an article looking at a single measurement of high-sensitivity troponin (see  MI single troponin aim2017  in dropbox, or doi:10.7326/M16-2562). Tomorrow, I will review an article looking at a somewhat more complex algorithm. Details: -- 9241 patients who presented to the emergency dept with possible acute coronary syndrome were evaluated in this collaborative meta-analysis from 11 prospective cohort studies in Europe, New Zealand, and Australia. A p ublicly-funded study, -- 64% male, mean age 61 -- Prevalence of acute MI range from 7-23% with an overall prevalence of 15% -- Study exclusion criteria were pretty consistent across the studies, but those with renal failure requiring dialysis were excluded in 3 of the studies and atypical presentation

The American Gastroenterological Association (AGA) just published a clinical practice update on the risks and benefits of long-term use of proton pump inhibitors (see  ppi  risks benefits AGA2017  in  dropbox , or  doi.org/10.1053/j.gastro.2017.01.031   ). Details: RISKS:  (these are the authors' assessment of the quality of the evidence and the effect sizes) kidney disease: 2 retrospective observational studies found a modest effect size (10-20%) of CKD in those on PPIs, with very low quality of evidence. Mechanism, unclear: ? if those on PPIs had more comorbidities which predispose them to kidney disease? dementia: retrospective observational studies finding a modest effect size (4-80%), with very low quality of evidence. Presumed mechanism: microglial cells use certain  ATPases  to degrade beta-amyloid, and PPIs may block these  ATPases  (which does increase beta-amyloid in mice) bone fracture: many observational studies, data inconsistent, modest effect siz

The American Gastroenterological Association (AGA) just published a clinical practice update on the risks and benefits of long-term use of proton pump inhibitors (see  ppi  risks benefits AGA2017  in  dropbox , or  doi.org/10.1053/j.gastro. 2017.01.031   ). Details: RISKS:  (these are the authors' assessment of the quality of the evidence and the effect sizes) kidney disease: 2 retrospective observational studies found a modest effect size (10-20%) of CKD in those on  PPIs , with very low quality of evidence. Mechanism, unclear: ? if those on  PPIs  had more comorbidities which predispose them to kidney disease? dementia: retrospective observational studies finding a modest effect size (4-80%), with very low quality of evidence. Presumed mechanism: microglial cells use certain  ATPases  to degrade beta-amyloid, and  PPIs may block these  ATPases  (which does increase beta-amyloid in mice) bone fracture: many observational studies, data inconsistent, modest effe

A recent systematic review and meta-analysis found that the use of protein pump inhibitors (PPIs) seems to be associated with increased recurrent Clostridium difficile infections (see  ppi   cdiff   metaanal  jamaintmed2017  in dropbox , or doi:10.1001/jamainternmed.2017.0212) Details: -- literature review from 1995 to 2015, specifically looking at case-control studies, cohort studies, and clinical trials, found 16 observational studies of 7703 patients with C. diff infections, 4038 (53%) were using gastric acid suppressants, and 1525 patients (20%) developed recurrent C. diff​ infections. -- These studies were performed in the United States, Korea, Israel, Europe, Japan, and Canada -- 9 studies involved PPIs alone, 5 with PPIs and H2 blockers, and one with H2 blockers alone. Results: -- the recurrence rate for C. diff was:     --22.1% (892 of 4038 patients) in those taking gastric acid suppression     --17.3% (633 of 3665) in those not taking gastric acid suppress

One perplexing issue in primary care is the appropriate duration of anticoagulation for people with unprovoked venous thromboses. A recent international study found that a specific clinical decision rule was effective in predicting recurrent DVT in women and could permit individualizing different therapies (see  dvt women HERDOO2 bmj2017  in dropbox, or  doi.org/10.1136/bmj.j1065 ​). Details: -- 2747 participants with a 1 st  unprovoked venous thromboembolism, VTE (either DVT with a noncompressible segment in the popliteal vein or more proximal leg veins and/or documented pulmonary embolism) who had completed 5 to 12 months of short-term anticoagulant treatment were followed prospectively from 44 healthcare centers in 7 countries (from North America, Europe, India, Australia), from 2008 to 2015. -- Mean age 54, 84% white, 75% on vitamin K antagonists for anticoagulation, VTE event was isolated DVT 41%/isolated PE 40%/DVT and PE 21% -- they used the HERDOO2 clinical decision

There been a few studies over the past suggesting a relationship between the gut microbiome and colorectal cancer, as well as between antibiotic exposure and colorectal cancer. An evaluation of the Nurses' Health Study recently confirmed prospectively that there was a dose-response curve between women's prior use of antibiotics and colorectal adenomas (see  microbiome antibiotics colon adenoma gut2017  in dropbox, or doi.org/10.1136/ gutjnl-2016-313413). Details: -- 16,642 women aged at least 60 who had at least one colonoscopy between 2004 and 2010 and had reported their antibiotic use in a 2004 questionnaire, comparing antibiotic users versus nonusers -- mean age 70, family history of cancer in 20%, diabetes in 9%, BMI 25, hormone therapy 20%, regular use of aspirin in 40%, multivitamins in 78%, 20 pack-years of smoking in those who were ever-smokers, 2.3 g of alcohol per day, 6 servings of red meat per week. Results: -- 1195 cases of adenomas were detected -