geoffrey modest medical blogs

The use of CT scans is increasing dramatically in kids. data collected from 7 large HMOs in the US over 10 years (2001-2011) in kids <15yo, with 4.9M child-years of observation (see  radiation exposure and cancer. jama peds 2013 in dropbox).  one advance in this study is that they collected the actual technical parameters (radiation dose) used in diverse facilities.   major findings: -- a doubling of CT scans done in kids <5yo over this 10-year spread (from 11 to 20 scans/1000 kids) and tripling in those 5-15 (from 10.5 to 25/1000 kids) -- with numbers leveling off or slightly decreasing in the later years. --large variability of radiation dose per scan at different sites. highest dosages overall with abd/pelvic CTs   (40% done for pain, 11% for r/o appendicitis, 6% for infection) --Head CT was the most commonly done CT and increased 50%, though the % increase was highest in abd CT  for children 5-14yo.  --using r...

as i've mentioned in several prior emails, there are pretty impressive data on the positive effects of a low glycemic index (GI) diet (ie one which documents the actual effect of different foods on the actual blood glucose levels). in general, high glycemic foods are associated with higher blood sugar levels and higher insulin levels in the early postprandial period, subsequently followed by low blood sugar levels (below the basal preprandial level), and associated increased hunger, food intake, and possibly weight.  also, high glycemic meals are associated with high triglycerides and lower HDL levels.  for an old but useful article, see  glycemic index ludwig jama 2002  in dropbox (or JAMA 2002; 287:2414-2423) for a more detailed physiologic description.   subsequent data have consistently found that low glycemic diets improve cholesterol/HDL ratios and are at least as good as low fat diets in decreasing weight (interestingly, several studies have shown that ...

Article in NY times today (see  http://www.nytimes.com/2013/04/08/health/study-points-to-new-culprit-in-heart-disease.html?nl=todaysheadlines&emc=edit_th_20130408&_r=0).seems  that presumptive coronary heart disease culprit of carnitine (in red meat, same Latin route at "carnivore") may be only partially correct. Published in Nature Medicine (see  cad red meat TMAO nature medicine 2013  in dropbox). Turns out to (maybe) be more complex:   --in regular meat eaters, eating a sirloin leads to an increase in TMAO (trimethylamine-N-oxide), which in lab studies leads to accumulation of cholesterol in macrophages and and also seems to decrease the ability to excrete excess cholesterol (for excruciating detail, see the paper itself), with some previous data that blood TMAO is assoc with CAD, both in humans and mice --in vegan who had a similar meal of sirloin (presumably with a significant bribe), no increase in TMAO. -- larger group of vegetarians give...

It is with extreme trepidation (and self-reflection) that i circulate the following article (see  cad and male pattern baldness bmj 2013  in dropbox). Meta-anal of 3 cohort and 3 case-controlled studies. 37K men. Results:   --cohort studies: for men with severe baldness, CAD with RR 1.32; in the case-controlled studies RR 1.70 --younger men (both <55 and <60)with similar RR=1.44 --using the Hamilton scale of baldness, vertex baldness assoc with CAD, with a "dose response curve":  severe vertex baldness RR 1.48, moderate with RR 1.36. mild 1.18. all significant.  but frontal baldness not assoc with CAD   In sum, these were observational studies and given the inherent problems sorting out multiple, complex risk factors, the 30% increase attributable to vertex baldness is really pretty small.  Perhaps we should do an intervention study.... Hair transplants for one group?????

3 recent articles on vitamin d (there are lots of them in the dropbox)   1.  JAMA article (see  vit d knee OA progression not help  in dropbox ) which randomized 146 people twith symptomatic knee osteoarthritis to high dose vitamin d (2000 IU/d) vs placebo for 2 years and evaluated symptoms and progression of cartilage loss. results:     -baseline vit d increased from 23 ng/ml to 39 ng/ml with therapy     -nonsignificant decrease in sx in vit d group vs placebo     -nonsignificant diff in cartilage volume loss, with sl less volume loss in vit d group     -if look at subset with lower vit d at baseline,  more improvement in both sx and cartilage with vit d than with placebo, but still nonsignificant   so, not so impressive results. reasons? maybe vit d is overrated. maybe better to treat people before they get symptomatic OA. maybe better results if patients with lower baseline vit ...

a recent article brought up the issue of H Pylori eradication in patients on low-dose aspirin (see  hpylori gi bleed asa gastro 2013  in dropbox). this is an observational, prospective study looking at 3 groups of patients on low-do se  asa.  followed up to10 years (5K patient-yrs), primary endpoint is recurrence of gastroduod bleed.   -- group 1:  250 pts with Hpylori and bleeding ulcer, had their Hpylori eradicated and continued with asa after the ulcer healed. - -group 2:120  Hpylori negative asa users who developed bleeding ulcers. put on enteric-coated asa after ulcer healed --group 3: 540 pts (considered their "average risk group") new pts on asa without a hx of ulcers   results: incidence of ulcer bleed, per 100-pt yrs -no diff in incidence of bleeding between group 1 (0.97 per 100 pt-yrs) and group 3 (0.66) -group 2 (bleeding despite being h. pylori neg) with 5.22 (ie 8.5x that of the average risk group)   ...

Very interesting article in BMJ on depression rx (See  depression resp to low intens interven bmj 2013  in dropbox), a meta-anal of 16 studies with 2470 pts. The standard of care in UK, per this article, is to stratify patients by degree of depression, and in those less severely depressed, provide "low intensity" psychological intervention, which is based on cognitive behavioral therapy but is provided through written materials or internet-delivered.  This is the first step of a stepped-care approach, which can step up to conventional high intensity intervention (12-16 therapy sessions of cognitive behav therap) if needed. However, the decision threshold of when to start with the low-intensity intervention is not so clear from the medical literature.  In this study/analysis, they looked at 2470 pts with depression. Turns out that some of these had moderate to severe depression and were still referred to the low-intensity group. And they followed the Beck Depression ...

NY Times piece on Sunday, see link below. Brings up several issues, including inappropriate incentives of fee-for-service system (leading to too many procedures, increased use of more expensive oncology meds), big pharma pushing remarkably expensive cancer drugs and some with very marginal benefit, and use of very expensive and largely unproved robotic surgery for cancer. See  http://opinionator.blogs.nytimes.com/2013/03/23/a-plan-to-fix-cancer-care/  .   Coincidentally, there was a strong editorial today in the boston globe (see  http://www.bostonglobe.com/lifestyle/health-wellness/2013/03/25/state-cautions-hospitals-about-patient-complications-during-robot-assisted-surgery/xOAsxR80qH5mVENDdktjKL/story.html?camp=newsletter  ) reporting that there is a Massachusetts health advisory about safety concerns with robotic surgery.  So, while hospitals had been flashing their new sexy, seductive, high-tech (and remarkably expensive) devices to lure patients t...