geoffrey modest medical blogs

A recent BMJ analysis article argued that taking the "full course of antibiotics" is often likely counterproductive (see  antibiotic length of therapy bmj0217  in  dropbox , or  doi : 10.1136/bmj.j3418 )​.  Details: --international health organizations and the WHO have pushed for completing antibiotic regimens: a 2016 WHO advisory to patients stated "always complete the full prescription, even if you feel better, because stopping treatment early promotes the growth of drug-resistant bacteria". The CDC has a similar message --the authors note that there is impressive evidence that some micro-organisms (eg TB, gonorrhea, HIV, S. typhi) can create spontaneous resistant mutations on treatment, and these mutants subsequently can be transmitted as resistant strains. [and there are good data supporting longer term therapies] --but many of the organisms with growing resistance worldwide are normal commensal flora (E coli, enterococci, staph, klebsiella, acinetob

A large longitudinal study of US veterans found a 25% increased risk of death associated with proton pump inhibitor (PPI) usage (s ee   ppi   and mortality bmj2017 in   dropbox , or doi.org/ 10.1136/ bmjopen-2016-015735) ​. Details: -- the researchers assessed three cohorts of patients, with 5.7 years of follow-up after the first acid suppression therapy prescription was written, and all patients had at least one outpatient serum creatinine value before acid suppression therapy was chosen:     -- primary cohort: new users of PPI or H2 blockers (n=349,312)     -- PPI versus no PPI users (n= 3,288,092)     -- PPI versus no PPI and no H2 blocker (n= 2,887,030) -- covariates assessed included age, race, gender, renal function, number of outpatient serum creatinine measurements, number of hospitalizations, diabetes, hypertension, cardiovascular disease, peripheral arterial disease, cerebrovascular disease, chronic lung disease, cancer, hepatitis C, HIV, dementia, and diseases

Some (likely) good news about prescription opioids from the CDC (see https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4.htm?s_cid=mm6626a4_w  ). -- Opioid prescribing in the United States between 2006 and 2015 peaked in 2010 at 782 morphine milligrams equivalents (MME) per capita then decreased annually to 640 MME per capita in 2015 -- there was pretty striking variation by US county, from 203 MME in the lowest quartile to 1319 MME in the highest; multivariate adjustment for many risk factors for opiate prescribing (more non-Hispanic white population, higher rates of uninsured and Medicaid, lower educational level, higher unemployment, living outside the urban areas, more dentists and physicians per capita, more diabetes/arthritis/disability, higher suicide rates) only accounted for 32% of the variation in prescribing [ie, there was much more to it than the expected risk factors... ?perhaps issues like the specific medical cultures in the different areas? other major differences in

​​The American College Of Gastroenterology and the Canadian Association of Gastroenterology updated their guidelines on the management of dyspepsia (see  dyspepsia guidelines ACG2017  in dropbox, or doi: 10.1038/ajg.2017.154​) Recommendations  (note: the recommendation is much weaker when they use the word “suggest” vs "recommend"): -- they suggest endoscopy for dyspepsia patients greater than 60 years old: conditional recommendation/very low-quality evidence. they raised the age from 55 of prior guidelines since the age-specific incidence of gastric cancer has fallen in the US, and they feel the cost of endoscopy per case of cancer detected is prohibitive. they also do suggest this guideline be individualized, so that for patients coming from areas with high upper GI malignancy rates there should be a lower threshold for endoscopy, especially those coming from Southeast Asia and some countries in South America. -- they suggest  not to do  endoscopy to investigate al

​ The BMJ just had an article assessing mortality from benzodiazepines from a large US commercial healthcare database, showing minimal increased mortality risk (see  benzos not increase  mortality BMJ2017  in  dropbox , or doi.org/10.1136/bmj.j2941). Details: -- 1,252,988 randomly selected patients, comparing those initiated on a benzodiazepine during a medical visit within the prior 14 days vs 1,252,988 non-initiators, from 2004-2013 -- all patients were required to fill at least one prescription for any medication both in the 90 days and 91- 180 days before the index date (ie, they were plugged into medical care and filling prescriptions), and high dimensional propensity scoring was done (see below). --  Mean age 46, 85% men, mean Charlson comorbidities score 0.5 (ie, low), 5% smokers, 4% obesity/overweight, 28% hypertension, 1% heart failure, 5% ischemic heart disease, 25% hyperlipidemia, 10% diabetes, 3% COPD, 5% asthma, 10% neuropathic pain, 20% back pain, 3% kidney dis

A recent meta-analysis found that the risk of sudden death in patients with symptomatic heart failure and reduced ejection fraction (HFrEF) has decreased significantly over the past 20 years (see  chf dec sudden death NEJM2017  in dropbox, or Shen L. N Engl J Med 2017; 377: 41). Details: -- 12 clinical trials  from 1999 through 2014,  in which patient-level data were available, included 40,195 patients, but excluded those with implantable cardioverter-defibrillators (ICD) -- Mean age 65, 77% men, 95% with NYHA class II or III heart failure, mean ejection fraction 28% (varied from 23% to 32%), 62% with ischemic heart failure, ACE-I/ARB use was >90%. -- sudden death was determined in 3583 patients   Results: --Those with sudden death were more often older  (low 60s vs mid 60s​) , male  (low 80% vs mid 70%) , had an ischemic cause of heart failure (70% vs 60%), and had worse cardiac function(LVEF 26% vs 29%). There was also minimally lower systolic blood p

The Multi-Society Task Force of Colorectal Cancer (MSTF), a combo of the Am College of Gastroenterology, Am Gastroenterological Assn, and the Am Society for Gastrointestinal Endoscopy, just published significantly revised guidelines on colorectal cancer (CRC) screening (see  colon ca screening guideline ACG2017  in  dropbox , or  doi : 10.1038/ajg.2017.174 ). Details: --They differentiate between programmatic screening/screening done in an organized system which involves consistent planning, documentation, monitoring of quality, and follow-up (which exists in many industrialized countries, as well as some healthcare plans/medical organizations in the US) vs opportunistic screening, which is largely up to the provider or designee to identify patients who need screening and arrange it -- given the potential for multiple different screens (9 are available), there are various approaches to the patient: offering the patient multiple options, though studies suggest that offering onl

A recent study looked at the racial/ethnic disparities in the development of interval colorectal cancer, defined as cancers that developed in a screened population but either were missed of the time of screening or developed de novo within the recommended screening/surveillance intervals  (see  colon ca screening inc interval ca in black pts AIM2017  in dropbox, or  DOI:  10.7326/M16-1154 ). Details: -- a population-based cohort study of  Medicare enrollees aged 66-75 who had colonoscopy between 2002 and 2011, followed through 2013, with  linkage to the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program -- total study population 61,433: 51,313 white/4196 black/2696 Asian/1164 Hispanic -- median age at index colonoscopy 70, 60% female (though higher in black and Hispanic persons), poverty level as defined by the ZIP Code of the patient's residence was high in 32% white/69% black/36% Asian/67% Hispanic, urban 83% white/89% black/ 98%