geoffrey modest medical blogs

a somewhat complex study in BMJ comparing the mortality benefit of exercise vs drugs in 4 diseases: secondary prevention of coronary heart dz, rehab of stroke, treatment of heart failure, and prevention of diabetes. looked at 300 trials and 340K patients. most trials either compared randomized controlled trials of exercise for these conditions, then compared to medication trials for these conditions (ie, almost all of the trials were not direct comparisons of exercise vs meds). see  exercise vs drugs mortality bmj 2013  in dropbox, or  BMJ  2013;347:f5577 doi: 10.1136/bmj.f5577 (Published 1 October 2013) .   results:   --the types of exercise interventions varied widely in the trials --some significant differences in trials with the baseline severity of disease (not so much for secondary prevention of MI, or CHF and impaired glucose tolerance. more so with stroke) --for secondary prevention of CAD, mortality odds ratios for meds: statins (OR 0.82),...

a somewhat complex study in BMJ comparing the mortality benefit of exercise vs drugs in 4 diseases: secondary prevention of coronary heart dz, rehab of stroke, treatment of heart failure, and prevention of diabetes. looked at 300 trials and 340K patients. most trials either compared randomized controlled trials of exercise for these conditions, then compared to medication trials for these conditions (ie, almost all of the trials were not direct comparisons of exercise vs meds). see  exercise vs drugs mortality bmj 2013  in dropbox, or  BMJ  2013;347:f5577 doi: 10.1136/bmj.f5577 (Published 1 October 2013) .   results:   --the types of exercise interventions varied widely in the trials --some significant differences in trials with the baseline severity of disease (not so much for secondary prevention of MI, or CHF and impaired glucose tolerance. more so with stroke) --for secondary prevention of CAD, mortality odds ratios for meds: statins (OR 0.82),...

non-alcoholic fatty liver disease is the most common cause of abnormal liver chemistries throughout the world, with purported incidence of 15-40% (16% in the recent NHANES3 data), often associated with obesity, metabolic syndrome, diabetes, dyslipidemia. we certainly see more NAFLD in patients with increased ALT than hepatitis C at the health center, which is also quite common. recent article found that weight loss was associated with reversal of NAFLD (see NAFLD wt loss j hepatol 2013 in dropbox, or  http://dx.doi.org/10.1016/j.jhep.2013.04.013#sthash.DTEHzjif.dpuf ). in brief:     --154 pts with NAFLD in community-based study in Hong Kong identified by increased ALT (median 43) and negative viral serologies/ANA, randomized to diet (dietician-led individual education weekly x 4 months, then monthly for 8 months, focusing on exercise and reducing calorie intake) vs control, assessing intrahepatic triglyceride content (IHTG) by proton-magnetic resonance spectroscopy a...

interesting study of patients who report prior history of penicillin allergy (see penicillin allergy skin testing j hosp med 2013 in dropbox, or DOI 10.1002/jhm.2036). 146 hospitalized patients with history consistent with IgE-mediated penicillin allergy were given penicillin skin testing (PST), which consisted of intradermal testing and, if negative, followed by test dose of oral penicillin.  they excluded patients with history of anaphylaxis. only one patient had a positive skin test. the remaining 145 with negative PST did fine with full course of oral penicillin. so negative predictive value of 100%. the results in this study, with <1% having positive PST, is lower than in some other studies, where it is as high as 20%. study significant because there are many patients with history suggestive of IgE-mediated penicillin allergy (eg, hives, urticaria, laryngeal edema, ...). the more specific the patient is about these symptoms, the more likely they have a true penicillin aller...

interesting study of patients who report prior history of penicillin allergy (see penicillin allergy skin testing j hosp med 2013 in dropbox, or DOI 10.1002/jhm.2036). 146 hospitalized patients with history consistent with IgE-mediated penicillin allergy were given penicillin skin testing (PST), which consisted of intradermal testing and, if negative, followed by test dose of oral penicillin.  they excluded patients with history of anaphylaxis. only one patient had a positive skin test. the remaining 145 with negative PST did fine with full course of oral penicillin. so negative predictive value of 100%. the results in this study, with <1% having positive PST, is lower than in some other studies, where it is as high as 20%. study significant because there are many patients with history suggestive of IgE-mediated penicillin allergy (eg, hives, urticaria, laryngeal edema, ...). the more specific the patient is about these symptoms, the more likely they have a true penicillin aller...

as many as you know, several of the medical professional organizations have submitted a list of 5 suggestions which they feel would decrease the use of unnecessary tests or treatments.  the most recent addition is from the American Society of Hematology, which I am circulating even though I'm not sure it's really helpful (they are focusing on very low hanging fruit).  see  choosing wisely hematology 2013  in dropbox, or  http://bloodjournal.hematologylibrary.org/content/122/24/3879.full.pdf+html . in brief, --In situations where RBC transfusions are necessary, transfuse the minimum number of units required to relieve symptoms of anemia or return the patient to a safe hemoglobin range (7-8 g/dL in stable noncardiac in-patients)  -- [transfusing more than is necessary does not improve outcomes and increases the potential risk] --do not test for thrombophilia in adult patients with venous thromboembolism occurring in the setting of major transient ris...

piece in new york times today (see  http://well.blogs.nytimes.com/2013/08/07/how-exercise-can-help-us-learn/?hpw ) which suggests that studying while doing low-level exercise improves memory.  there was also an article in one of malcolm gladwell's books finding that, in a crossover study, kids that exercised before an exam had a dramatic improvement in their scores, as compared to no exercise. unfortunately, the trend in society is to cut out exercise as part of the school curriculum, and it continues to be very difficult for many of us (including my patients) to fit exercise into our over-determined/overcommitted daily schedules

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...