geoffrey modest medical blogs

A recent review article addressed an important point regarding antibiotic overuse and the increased potential for microbial resistance: the frequent use of nonprescription antibiotics (see  antibiotics without scripts AIM2019  in dropbox, or doi:10.7326/M19-0505). Details: --31 studies reporting nonprescription use of antibiotics, storage of antibiotics for future use, and intention to use antibiotics without a prescription --4 populations studied:      --patients or parent of patients surveyed outside of health care settings (eg random phone interviews)     --patients or parent of patients surveyed within health care settings (eg EDs and primary care)     --Hispanic/Latino populations     --injection drug users (specifically, self-treatment of abscesses and injection-related wounds) Results: --prevalence of nonprescription antibiotic use: varied from 1% to 66% --storage of antibiotics for future use: varied from 14% to 48% --prevalence of intention to use antibiotics wit

Another dementia study. This one finding that increased cognitive stimulation and social connections and support are associated with reduced risk of dementia (see dementia dec with inc cognit reserve jamaneuro2019 in dropbox, or doi:10.1001/jamaneurol.2019.2455) Details: --1602 participants free of initial dementia in the Rush Memory and Aging Project, a community-based cohort study with annual follow-up from 1997-2018 --baseline: 76% women, mean age 80, education 15 yrs, never smokers 57%/ever 40%/current 3%, alcohol 61% never or occasional/28% light-to-moderate/12% heavy, BMI 27, MMSE 29 (out of 30), heart disease 9%/hypertension 68%/cerebrovasc dz 9%/diabetes 15, APOE e4 20% --mean follow-up 6 years, max 20 years, providing 9722 person-yrs of follow-up --611 people died and had autopsies during follow-up --they assessed “cognitive reserve” (CR), measured by the proxy construct of education, and social and cognitive activities:     --education: years of educ

A large study found that genetic risk and lifestyle both played a role in the development of dementia, and that their roles were independent of each other (see  dementia lifestyle  dec  risk w genetic risk jama2019  in dropbox, or JAMA. doi:10.1001/jama.2019.9879) Details: --retrospective study of adults of European ancestry without baseline cognitive impairement who were in the UK Biobank, a population-based cohort of >500,000 people, from 2006-2010 --196,383 people were followed for 8.0 years, with 1,545,433 person-years of followup --mean age 64, 47% male, 42% had higher education, 60% in the middle 3 SES quintiles, 92% not current smokers, 77% regular physical activity, 51% healthy diet, 56% moderate alcohol consumption, 4% history of stroke, 18% depressed in the past 2 weeks     --of these demographics, more in the group with dementia were: male (55 vs 47%), had higher education (42 vs 31%), were in the lowest SES (28 vs 20%), were depressed in the past 2 w

A hospital-based study found that 2/3 of patients with pneumonia received longer courses of antibiotics than necessary, with more reported adverse outcomes (see pneumonia excess abx AIM2019 in dropbox, or doi:10.7326/M18-3640) Details: --6481 medical patients from 43 hospitals in the Michigan Hospital Medicine Safety Consortium, a collaborative sponsored by Blue Cross/Blue Shield, from 2017-18 --mean age 70, 80% white, 51% female, median Charlson Comorbidity Index score 3 (an array of comorbidities which predict mortality within 1 year of hospitalization, with a score of 3 suggesting moderate severity of comorbidities) and, specifically, CKD 29%/CHF 27%/COPD 46%/home oxygen 16%/current or former smoker 67%/diabetes 31%/cancer 22% --pneumonia severity score: >75% had class III to class V (ie more severe disease, as determined by age, comorbidities, vitals, lab abnormalities, pleural effusion) --26% had concurrent COPD exacerbation] --54% with sepsis; median symptoms

since i am doing a few blogs on antibiotic overuse and concerns about increasing drug-resistant bacteria, i thought i would add another one on antibiotic-resistant E. coli causing urinary tract infections, per the NY Times on 7/14/19 (see  https://www.nytimes.com/2019/07/13/health/urinary-infections-drug-resistant.html?smid=nytcore-ios-share  ) Details/Comments: --UTIs are among the most common infections in the world --the number of hospitalizations from UTIs has increased 52% from 1998-2011, especially for women and older patients (see  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5414046/  ) --there has been increasing E coli resistance to trimethoprim/sulfamethoxazole (TMP/SMX), with the NY City Dept of Health reporting 1/3 are resistant (as we have certainly seen in Boston over the past few decades) and 1/5 are resist an t to 5 other common treatments     --a Lancet editorial on the 2018 NICE (National Institute for Health and Care Excellence in the UK) draft guideli

A few recent articles  found that t oo many antibiotics  were being  prescribed for pulmonary conditions.  will review an article on using CRP levels to guide antibiotic prescribing (see  copd CRP guided abx nejm2019  in dropbox, or DOI: 1 0.1056/NEJMoa1803185). will do a subsequent one on overprescribing antibiotics in patients in the hospital with pneumonia Details: --653 patients in 86 general medical practices in UK who presented with an acute exacerbation of COPD were randomized to usual care guided by CRP point-of-care testing vs usual care alone --mean age 68, 50% male, 7 days of symptoms prior to seeing clinician, Clinical COPD Questionnaire score 3.2 (a 10-item scale with scores from 0 reflecting good COPD status to 6 reflecting very poor status), FEV1/FVC=0.6, FEV1=59% of predicted, COPD severity: mild 11%/moderate (GOLD stage 2) 54%/severe (GOLD stage 3) 30%/very severe (GOLD stage 4) 5%, prior antibiotics in past 12 months 67%, use of regular inhalers 96%