geoffrey modest medical blogs

A recent review assessed patients with mid-range ejection fraction, elaborating on its epidemiology, pathophysiology, prognosis, and management (see Hsu JJ. JACC: Heart Failure; 2017; 5 (11): 763). This entity was  first codified in 2013 in guidelines from the Am Heart Assn and European Society of Cardiol.  Main points: --definition: --HFrEF (heart failure with reduced ejection fraction) is with EF <40 (per AHA), <41 (per ESC) --HFpEF (preserved EF) is with EF>=50 (both agree) --HFmEF (mid-range EF) is with EF 40-49 (AHA), or EF 41-49 (ESC). --epidemiology: --of the 6.5 million people in the US with HF, about 1.6 million have HFmEF (13-24% of the total), and this has remained pretty steady from 2005-2010, whereas HFpEF has increased from 33 to 39% and HFrEF decreased from 52 to 47% --clinical characteristics:     --the actual clinical characteristics are a bit fragmentary as they are largely based ...

A recent article brought to my attention (thanks to Paul  Susman ) presented an important conceptual and mathematical framework to assess the potential communicability of microorganisms (see  https://portside.org/print/2017-11-06/unforgiving-math-stops-epidemics ​ ). And I think this article provides a good basis for discussing immunization with patients, and in particular the importance of flu vaccine, given the large number of people who decline it (the groups who "I never get the flu" or "I got the flu from the vaccine"  etc ) Details: --there are some specifics of the microorganism infectivity that govern its spread:     --the R 0  of the microorganism (basic reproduction number) varies widely, and is not necessarily what we in clinical medicine would have assumed. And knowing this number allows easy calculation of the level of herd immunity needed in the population to prevent its spread (herd immunity being that % of t...

I had done a blog many years ago of a review article arguing that torsemide was a more useful loop diuretic overall, and specifically in heart failure, than our much more commonly used furosemide (see Wargo KA. Ann Pharmacother 2009;43:1836-47).  A recent review article on "Diuretic Treatment in Heart Failure (see Ellison D. N Engl J Med 2017;377:1964​) commented that "when administered orally, furosemide has a limited and highly variable bioavailability (mean, approximately 50%, range 10 to 90)" and as a result the IV dose is half the po dose, food delays its absorption, the half-life for its excretion is shorter than its GI absorption rate, and in those with acute decompensated heart failure, a higher peak level may be required (and necessitating an IV dose, though gut edema may contribute some to this). In contrast, torsemide has a higher and more consistent oral bioavailability of >90% (so its po and IV doses, for example, are the same), and a longer half-life in...

Another article just came out in the Lancet finding a lack of benefit from a commonly done surgery vs sham surgery, this time for arthroscopic subacromial decompression for subacromial shoulder pain (see  doi.org/10.1016/S0140-6736(17)32457-1). Details: --313 patients from 32 hospitals in the UK, with 51 surgeons. From 2012-15. --mean age 53, 50% female, baseline Oxford Shoulder Score (OSS) was 29 (scale of 0-48, with 0 being worst; this scale basically sums patient symptom scores over the prior 4 weeks, including their ability to get dressed, carry things, other activities of daily living; plus other scores for anxiety/depression, pain and quality of life. At baseline, all were mostly midrange, though depression/anxiety was in the lower range (less bad) --all patients had subacromial pain for at least 3 months, had intact rotator cuff tendons, and had completed a non-operative management program that included exercise therapy and at least one steroid...

so, just after i was sent out the email/blog yesterday, this came through:  “FDA Opens Door to Wider Avandia Prescribing” – see  http://www.medpagetoday.com/Endocrinology/Diabetes/43110?xid=nl_mpt_DHE_2013-11-26&utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&eun=g748274d0r&userid=748274&email=gmodest@uphams.org&mu_id=5928254 , or your local newspaper. has the slight whiff of the hand of big pharma.....   i can’t figure out why this is an issue (expect from drug company pressure). the data are pretty clear that rosiglitazone (avandia) in several studies is associated with more clinical heart disease.  it has adverse lipid effects. and, if one were to choose a glitazone, there are data that pioglitazone is beneficial to lipids and leads to favorable cardiac outcomes  (see dm pioglit PROACTIVE study. lancet 2005, or  Lancet  2005; 366: 1279–89).   and the beat goes on. 

​ Two recent articles found relationships between the gut microbiome and hypertension (see doi:10.1038/nature24628 );​ and between the skin microbiome and atopic dermatitis ( see  DOI: 10.1126/scitranslmed.aah4680 ). -------------------------- Gut microbiome and hypertension. Details: --in mice:     --high salt diet led to increased blood pressure as well as gut microbiome changes: eg, depletion of Lactobacillus murinus within one day of the high salt diet     ​--concomitant high salt diet and repletion of L. murinus led to a decrease in systolic and normalization of diastolic blood pressures     ​--other studies suggest that high salt diet leads to induction of T H 17 cells (T helper 17 cells), which depends on the gut microbiota     ​--in this study high salt diet led to led to pretty specific increases in the mouse T H 17 cells, and these lev...

The Lancet just published a study (X:BOT) comparing extended-release naltrexone (XR-NTX) with buprenorphine/naloxone (BUP-NX) for opioid relapse prevention, this one with 6 months of follow-up, showing similar safety and efficacy of the 2 therapies (see  doi.org/10.1016/S0140-6736(17)32812-X). Study sponsored by  National  Institute on Drug Abuse. [i appreciate and have incorporated the inputs from Ian Huntington and Joe Wright]   Details: --570 people from 8 US community-based programs --70% male, mean age 34,75% white/18% Latino/10% African-American, 63% unemployed --64% injection drug use, primary opioid in prior 7 days: 80% heroin/16% opioid analgesics (prescription pills)/2% buprenorphine/1% methadone, age of onset of opioid 21 yo,duration of use 9 yrs, 50% also on stimulants/30% sedatives/25% heavy alcohol/45% cannabis, 68% psychiatric disorder, 7% depressed.  --most had low-severity opioid use (th...

The American College of Cardiology, the American Heart Association, and 9 other societies just released their 2017 guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults (go to  https://doi.org/10.1161/HYP.0000000000000065  and download PDF ). Below are the main points and changes over prior documents, focusing on primary care (i did not comment on in - hospital or urgent treatments) . It is a bit long, but much shorter than the 283 page document: Details: -- hypertension is remarkably common in the US, and likely to become more common with the aging population: the Multiethnic Study of Atherosclerosis found that for 45-year-olds without hypertension, the 40-year risk of developing it was: 93% African-American, 92% Hispanic, 86% for white, and 84% for Chinese adults. The Framingham study found 90% likelihood of developing hypertension during one's lifetime if free of hypertension at age 55 to 65. -- the vas...