geoffrey modest medical blogs

study reported in BMJ finding a relationship between current NSAID use and development of atrial fibrilliation (see  afib and nsaids bmj 2014  in dropbox, or doi:10.1136/bmjopen-2013-004059). they looked at a group within the ongoing Rotterdam Study, a prospective community-based study of elderly. 8423 people without afib at start (mean age 68.5, 58% women), followed 12.9 yrs and matched the dx of afib (either by sx or by ekg routinely done at each followup exam) with the pharmacy records (i’m not sure if nsaids are available there OTC and not recorded in database...). adjusted for risk factors of bmi, lipids, bp, diabetes, hx MI, age, sex, smoking chf. results:             --857 pts developed afib --current users of nsaids for 15-30 days had 76% increase in risk of afib [HR 1.76 (1.07-2.88)]             --use within 30 days of discontinuation of nsaids also w...

lancet with huge study (1.8M) of 97 prospective cohorts from around the world, looking at the independent role (ie controlling for blood pressure, cholesterol and glucose) of BMI, overwt, and obesity on coronary heart dz (CHD)  and stroke (see  cad risk bmi lancet 2014  in dropbox, or doi.org/10.1016/ S0140-6736(13)61836-X). studies done from 1948-2005, with 2.7-57.5 yrs of follow-up. results:     --each 5  kg/m 2    inc BMI was assoc  with  HR 1.15 (1.12-1.18) for CHD and HR 1.04 (1.01-1.08) for stroke,  after adjusting for bp, chol, and gluc.     --these HRs suggest that 46% of excess risk of BMI for CHD and 76% of excess risk for stroke were mediated by these 3 risk factors (and  54% of BMI-attributable risk for CHD was not explained by them/24% for stroke ).     --of the 3 risk factors,  blood pressure was the major mediator of excess risk, accounting for 31% of the excess risk for CHD and 65...

recent review/meta-anal of cardiovasc events/mortality in diabetic pts on ACE-I vs ARBs (see  dm ace vs arb jamaintmed 2014  in dropbox, or doi:10.1001/jamainternmed.2014.348). this analysis looked at 35 studies, mostly ACE-I vs placebo or active control (22 in all, 11 placebo, most of others with CCB) and ARBs vs placebo or active control  (13 in all, 9 placebo). results:     --ACE-I reduced risk of all-cause mortality 13% [RR 0.87 (0.78-0.98)], cardiovasc deaths 17% [0.83 (0.70-0.99)], major CV events 14% [0.86 (0.77-0.95] with MI dec 21% [0.79 (0.65-0.95)] and heart failure 19% [0.81 (0.71-0.93)]. no diff in studies if comparison to placebo or active control.     --ARBs reduced CHF 30% [0.70 (0.59-0.82)], but no significant decrease in major CV events overall and no signif decrease in either of the mortality outcomes. similar results if compared to placebo or active med. olmesartan may be a bad actor (2 studies showed increased de...

vitamin D deficiency has been associated with many different medical conditions noted over the past decade, presumably related to there being vitamin d receptors on almost cell types in the body. in general, vitamin D supplementation has been shown to benefit rickets, fractures and falls (though recent meta-anal did not find consistent positive effect on bone density). there are also strong associations with multiple sclerosis, an array of autoimmune disorders, infections, cardiac disease, and cancer. the dropbox has a slew of articles beginning with "vit d", some showing increased insulin sensitivity or improved lipids with vitamin d supplementation, one showing improved response to TB infection by antiTB drugs when simultaneously given vitamin D. the data on vitamin D and risk of non-skeletal diseases, however, is still unclear, and the 2011 endocrine society guidelines clearly recommend vitamin D only for the proven skeletal issues (see  vit d Endocrine Guidelines 2011  i...

front page article in NY Times on excessive (extortive) costs of medical equipment/meds (see  http://www.nytimes.com/2014/04/06/health/even-small-medical-advances-can-mean-big-jumps-in-bills.html?hp  ). from my extrapolation (pretty crude) of their graph, between 1987 and 2008, outpatient costs have stayed flat at about $750, inpatient costs have gone down a bit from $1550 to $1400, while prescription drugs increased from $450 to $2200. the article highlights type 1 diabetes and insulin pump therapy, though mentions the dramatic increase in costs for rheumatoid arthritis, etc [on that note, it was a great pleasure sending out the blog on rheum arthritis drugs last june -- will append to end of this blog]. they highlight a woman with an insulin pump. cost of pump $26,400. her cost after insurance $4224. monitor probes at $100 and need to be replaced every 6 days, disposable tubing replaceable every 3 days, 10 or so teststrips (which can be $1.50/strip),  and insulin wh...

recent followup study to the original POISE trial in the lancet, which found that pre-op b-blockers (metoprolol) did not improve post-surgical outcomes after noncardiac surgery in high risk vascular patients (risks outweighed benefits). NEJM had recent article on aspirin (see  aspirin noncardiac surg high risk nejm 2014  in dropbox, or DOI: 10.1056/NEJMoa1401105). in this trial 10K patients from 23 countries at risk for vascular complications (>45yo, with history of at least one of: CAD, PAD, stroke, major vasc surgery, or over age 70 with high risk of CAD) and about to undergo noncardiac surgery were assigned either aspirin vs placebo or clonidine vs placebo. for the aspirin group, they assessed 2 subgroups, those who were not previously on aspirin (initiation stratum, 5628 pts) and those previously on aspirin (continuation stratum, 4382 pts). those in the initiation group were given ASA 200mg just before surgery and 100mg/d after for 30 days. those in the continuati...

JAMA had an interesting/disturbing letter documenting extensive representation of Academic Medical Centers on the boards of the largest pharmaceutical companies (see  pharmaceut board and academ med ctr jama 2014  in dropbox, or    doi:10.1001/jama.2013.284925 ).  47 of the largest 50 pharmaceutical companies in the world were evaluated based on 2012 data. Findings: --40% of the drug companies had a least one board member who was in a leadership position at an Academic Medical Center.  --16 of the 17 US companies (94%) had at least one such board member.  --And, on reviewing the data provided in the article, Harvard/Partners/Mass General were quite well represented, being on 3 different boards and making    an average of about $320,000 for those individuals.  Unfortunately, the names of the specific individuals involved was withheld. As I have mentioned before, there has been a fundamental shift in medical research over ...

the boston globe ran a story today pointing out the marginal benefit of mammography from a recent analysis --see below, but they had a thoughtful summary (see  http://www.bostonglobe.com/lifestyle/health-wellness/2014/04/02/doctors-may-oversell-mammograms-benefits-mammograms-may-have-been-oversold-study-suggests/cA0Djh3Xj3uqGMBKxESYQO/story.html  ) the article just came out in JAMA  (see   mammog screening review jama 2014   in dropbox, or doi:10.1001/jama.2014.1398)  and reinforces the not-so-great efficacy of mammog screening, confirming what i sent out in several recent blogs.  they did literature search finding 8 large RCTs (all done between the 1960s and 1990s, which may be an issue: see below) finding a 15-20% decreased breast cancer mortality. another meta-anal from canadian task force found 19% decrease after 11.4 yrs of followup. the new JAMA data (see tables below) includes the relative risk (RR), absolute risk reduction (ARR), overdiagn...