geoffrey modest medical blogs

Geoff, I enjoyed this submission.  I have been thinking a lot about AF screening recently. I think it is an important issue despite the fact that the most recent AHA AF guidelines do not even mention screening. ESC recommends “ opportunistic screening”, ie pulse palpation followed by EKG if pulse abnormal/irregular- based on just a few studies. Many barriers to screening, and you alluded to some of them. With the advent of automatic BP cuffs, many clinician do not routinely  palpate their patient’s pulse. One solution, which is more commonly used in Europe, is the adoption of “ AF detecting BP cuffs” that assess pulse irregularity and using a fairly reliable algorithm signal if AF is “suspected”. In several studies these BP cuffs were shown to be as good at correctly diagnosing AF as clinicians reading a 12 lead EKG. We are in the process of bringing these cuffs in to a few of the busier PCP practices and I am contemplating recommending these cuffs for my over 65 y...

A recent trial released at the 2018 Am Heart Assn meetings found that an eicosapentanaenoic acid (EPA) derivative (a fish oil variant) decreased cardiovascular outcomes in patients with high cardiovascular risk, had high triglyceride levels, and were already on a statin with low LDL levels (see  cad triglyc reduct benefit nejm2018 in dropbox, or DOI: 10.1056/NEJMoa1812792) Details: --8179 patients were enrolled, all with established cardiovascular disease or with diabetes and at least one other risk factor, on statin therapy with LDL 41-100 mg/dL, but ha d a fasting triglyceride (TG) level of 135-499 mg/dL --median age 64, 71% male, 90% white, BMI 31, 71% from US/Canada/Netherlands/Australia/New Zealand, 26% Eastern Europe, 100% on statins / 6% ezetimibe, 58% diabetes --71% of the patients were enrolled for secondary prevention, 29% primary prevention of cardiovascular events --median hs-CRP 2.2...

Two related articles on atrial fibrillation (AF), both situations with AF undertreatment and increased stroke risk ------------------------------------------- A recent study found that those who had atrial fibrillation following noncardiac, non-obstetrical surgery were at higher risk of thromboembolic events in the future (see  afib periop as bad as nonvalv AF jacc2018  in dropbox, or doi.org/10.1016/j.jacc.2018.07.088 ). Details: -- Denmark has extensive and pretty complete national registries documenting: individual level registration; all hospital admissions and outpatient contacts; medicinal product dispensing date, strength, and quantity; and a civil registration system information on vital status, birth date, and sex -- a retrospective review was done including all patients who developed postoperative atrial fibrillation (POAF) following noncardiac surgery from 1996 to 2015; none had a history of AF, or outpatient diagnosis of AF, or pres...

The FDA issued a pretty strong position on the sale of flavored tobacco products to kids: see  https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm625884.htm  , which is  basically a somewhat personalized statement by the FDA's commissioner Scott Gottlieb Gottieb notes recent data from MMWR (see  https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm  ) finding: -- from 2017-2018, a 78% increase in current e-cigarettte use among high school students (from 11.7% to 20.8%, p<0.001), and  a 48% increase among middle school students --use of e-cigarettes: 3.05 million (20.8%, 1.5 million more) high school students, and 570,000 (4.9%, 510 000 more) middle school students --regular e-cig users (>20 days in past month) increased from 20.0% to 27.7% (p=0.008) --flavored e-cigs users increased from 60.9% to 67.8% (p=0.02) ; current use of menthol or mint-flavored e-cigs increas...

the Am Acad of Pediatrics just published their 5 concerns about antibiotic prescribing (see  http://www.choosingwisely.org/societies/american-academy-of-pediatrics-committee-on-infectious-diseases-and-the-pediatric-infectious-diseases-society/  . Published on the Choosing Wisely website  http://www.choosingwisely.org/  , developed to “advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures”. Don’t initiate empiric antibiotic therapy in the patient with suspected invasive bacterial infection without first confirming that blood, urine or other appropriate cultures have been obtained, excluding exceptional cases.  The issue here, i assume (not explicitly stated) is that we may be treating non-bacterial infections (eg we may be not treating a viral infection appropriately, or may be giving antibiotics for a non-infectious process); and even for a bacterial infection, it may be hard to figure out what the best oral a...