geoffrey modest medical blogs

A recent randomized clinical noninferiority trial from Norway found that extended-release naltrexone was as noninferior to (and seemingly superior to) buprenorphine-naloxone in maintaining short-term abstinence from heroin (see doi:10.1001/jamapsychiatry.2017.3206). Details: --159 people were randomized to daily oral flexible-dose buprenorphine-naloxone (4-24 mg/d, target dose 16 mg/d) vs extended-release naltrexone 380mg intramuscularly every 4 weeks, for 12 weeks --mean age 36, 28% women, 90% white, 85% intravenous users, 3% HIV positive, 55% hepatitis C seropositive, approx 7 years of substance use --all patients went through an inpatient detox program (or were in prison/off drugs) for at least 7 days prior to starting the study --weekly drug testing Results: --mean daily dose of buprenorphine was 11 mg/d --105 people (66%) completed the study (attended all scheduled appointments, took meds as prescribed) --retention rate for naltrexone was non-inferior to buprenorphine,

 The FDA just approved a second herpes zoster  vaccine for adults aged >50. There is no formal FDA announcement, just one by the manufacturer (see  https://www.gsk.com/en-gb/media/press-releases/shingrix-approved-in-the-us-for-prevention-of-shingles-in-adults-aged-50-and-over/ ). Details: --Shingrix (Zoster Vaccine Recombinant, Adjuvanted) was approved for the prevention of zoster in adults aged 50 or older --the vaccine is a non-live vaccine, administered intramuscularly in 2 doses --this vaccine was approved in Canada for people over 50yo in October 2017 Relevant recent studies: (both done by the same research group and drug-company supported) 1.  Lal, H. N Engl J Med 2015; 372:2087     --15,411 people from 18 countries were randomized to a subunit vaccine containing varicella-zoster virus glycoprotein E and the AS01 B adjuvant system (called HZ/su), vs placebo.      --During followup of 3.2 years, herpes zoster infection was confirmed in 6 of those in the

A recent article using mathematical modeling found that smokers who have well-controlled HIV infection are much more likely to die from lung cancer than AIDS-related conditions (see doi:10.1001/jamainternmed.2017.4349 ) Details: --they used a validated Monte Carlo microsimulation model of HIV, the CEPAC-US model (Cost-Effectiveness of Preventing AIDS Complications), which includes lots of data on distributions of CD4 counts, HIV viral loads, age, sex, smoking status, treatment, etc. Individuals are entered into the simulation model at a specified time of linkage to HIV care and their outcomes are assessed at projected death or until age 80; they modeled cohorts of 1 million men or women with specific smoking exposures at specific ages --smoking was divided into heavy (35 cigarettes/d), moderate (18 cigs/d), and light (2 cigs/d); former smokers were considered to have stopped at the age of entry into the model Results: --Cumulative lung cancer mortality by age 80, in the

A recent review assessed the role of the Mediterranean diet for those with nonalcoholic fatty liver disease (NAFLD), finding that this diet decreased hepatic steatosis even without weight loss ( see DOI: 10.1111/liv.13435​ ). For detailed prior assessments of NAFLD, see the array of blogs at http://blogs.bmj.com/bmjebmspotlight/?s=NAFLD&submit=Search . Details: -- NAFLD is remarkably common and the potential cause of significant liver-related morbidity and mortality. Also increase in overall mortality as well as risk of developing type II diabetes and cardiovascular disease -- the main treatment of NAFLD at this point is through lifestyle interventions, especially weight loss in those overweight (though  http://gmodestmedblogs.blogspot.com/2017/06/nature-vs-nurture-studies-on-lipids-and.html   highlights the significant incidence of NAFLD in lean individuals as well) -- the Mediterranean diet (MD), one that has relatively high intake of plant-based foods (vegetables, fruits a

Just as I sent out the last HPV blog (see  http://gmodestmedblogs.blogspot.com/2017/10/primary-cervical-hpv-screening-and.html ,which argues for primary HPV cervical screening in women, and notes the  dramatic 97% efficacy of the 9-valent HPV vaccine), this article appeared showing very high rates (12%) of men are infected with oral HPV (see doi:10.7326/M17-1363), a study sponsored by the National Cancer Institute. Details : --Population: Adults aged 18-69 from the 2011-2014 NHANES (National Health and Nutritional Examination Survey), self-reported data from 4493 men and 4641 women Results : --Overall prevalence of oral HPV infection was 11.5% in men and 3.2% in women, suggesting infection in 11 million men and 3.2 million women in the US --High-risk oral HPV infection was found in 7.3% of men and 1.4% of women, which translates  to 7 million men and 1.4 million women     ​--Oral HPV-16 infection, the type conferring the highest oropharyngeal cancer risk, was found i

in February 2017, the US FDA approved using  procalcitonin  as a marker to guide antibiotic therapy in patients with acute respiratory infections, indicating that this assay could be used to determine if "antibiotic treatment should be started or stopped in patients with lower respiratory tract infections, such as community-acquired pneumonia, and stopped in patients with sepsis".  (see  https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm543160.htm  ). a recent meta-analysis confirmed that  procalcitonin -guided therapy reduced antibiotic exposure and adverse events, and improved survival in hospitalized patients (see  doi.org/10.1016/ S1473-3099(17)30592-3). Details: --26 randomized trials, 6708 patients from 12 countries     --mostly from  Europe , but some from China, Brazil, US, Australia     --mean age 61, 57% men, 49% in ED/37% ICU/15% primary care     --primary diagnosis:          --URI 9%         --lower respiratory tract infection 92%: 44%

Primary HPV cervical cancer screening (ie only testing for cancer-associated HPV types) is superior to cytology screening as shown in many prior studies, but now found in Australia, a country with very high rates of HPV vaccination ( see  http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002388 ​  ​).  Details: --by 2014, women <34 yo were eligible for HPV vaccination, with 3-dose vaccination rates being 50-77% --this Compass trial was an open-label randomized trial of 5-yearly HPV screening versus 2.5-yearly liquid-based cytology (LBC) screening, with 3 options:     ​--LBC screening: image-read LBC screening with HPV triage of low-grade cytology. Colposcopy if HPV positive or HSIL. routine screen in 2.5 years if negative initial screen     --HPV+LBC screening: HPV screening along with partial genotyping, with women positive for HPV 16/18 referred to colposcopy, and those women with other oncogenic HPV types getting LBC. referral for colposcopy if L

2 small studies evaluated the efficiency of differing ways to supplement oral iron in iron-deficient women (See doi.org/10.1016/ S2352-3026(17)30194-1). Details: --all women were age 18-40 with documented serum ferritin levels <25 mcg/L --Study 1:     ​--40 women, median age 22,  given iron repletion with 60 mg iron at 0800h daily for 14 days vs 60 mg iron every other day for 28 days     --baseline mean hemoglobin 13, ferritin 13.8, Fe/TIBC= 18/82 (in  m M), transferrin saturation 22%, serum hepcidin 0.8 nM,  --Study 2:     --20 women, median age 27, were given 120 mg iron at 0800 h vs 60 mg at 0800h plus 60 mg at 1700 h for 3 consecutive days.  then, after 14 day washout, these groups were switched      --baseline mean hemoglobin 13,  f erritin 20, Fe/TIBC= 17/80 (in  m M), transferrin saturation 21%, serum hepcidin 0.8 nM,  --co-primary outcomes in both studies: iron bioavailability (total and fractional iron  absorption , assessed by  isotopic  label abundanc