geoffrey modest medical blogs

there has been more chatter in the medical literature about the pluses and minuses of routine low-dose CT screening for lung cancer in smokers. given that the USPSTF endorsed this, i decided to send out again an old blog analyzing the study on which the recommendations were based (National Lung Screening Trial, NSLT) and critique of the recommendations, as below. a recent article in the NY Times (i believe) noted that Medicare would not cover until 2015, which is later than expected, ??suggesting they are rethinking this recommendation??? i added some specific issues with the recommendation at the bottom of the blog. -------------------------------- this is from the Boston Globe today (ie 12/31/13): Current cigarette smokers ages 55 to 80 who have smoked the equivalent of a pack a day for 30 years, or people who had those same smoking habits within the past 15 years, should be screened, advised the US Preventive Services Task Force, a group created by Congress. Under the ...

Cook and Ridker initially challenged the AHA guidelines on lipid management by looking at 3 datasets showing that they dramatically overpredicted cardiac events by 75-150% through the new AHA risk calculator. they just published a further analysis of the Women's Health Study (see  chol AHA guideline womens health study JAMA intmed 2014 in dropbox, or doi:10.1001/jamainternmed.2014.5336). T he Women's Health Study was an aspirin/vitamin E intervention trial of a nationwide cohort of 27,542 US women aged 45-79 (ave age of 54.2, 1.8% Black), initially free of  cardiovascular disease, cancer or other major illnesses (overall healthy cohort: 11.6% smokers, 2.5% diabetic, 13.5% on antihypertensives). these women had lipids and other risk factors assessed and were followed 10.2 years. results:     --average cholesterol 212, LDL 124, HDL 54     --632 women had a cardiovasc event o...

The Am College of Physicians just released practice guidelines for the nonsurgical management of urinary incontinence in women (see  urinary incontinence in women guidelines ACP 2014 in dropbox, or doi:10.7326/M13-2410​).  baseline issues:     --urinary incontinence is really common: 25% in women aged 14-21; 44-57% in middle-aged and postmenopausal women aged 40-60; 75% in those >75 yo (though likely that these numbers reflect under-reporting)     ​--risk factors: pregnancy, pelvic floor trauma after vaginal delivery, menopause, hysterectomy, obesity, UTI, functional and/or cognitive impairment, chronic cough, constipation     ​--2 main types: stress incontinence from urethral sphincter failure with increased intra-abdominal pressure (eg from laughing, coughing, sneezing) and urge incontinence from involuntary loss of urine from compelling urge to void. there are also mixed incontine...

the American Academy of Neurology just published a position paper on the use of opioids for chronic noncancer pain, or CNCP, lasting more than 3 months (see  opioid guidelines neurology 2014 in dropbox, or doi: 10.1212/WNL.0000000000000839). their basic argument is that there are no data showing that longer term opioids are effective (though they do acknowledge that none of the randomized controlled trials lasted more than a few months). a cross-sectional Danish study found that those with chronic pain on opioids reported that  over time they had decreased pain relief, functional capacity and quality of life vs those not on opioids, "adjusting for severity" (i'm not sure what that means. a little hard to imagine that they can really adjust for severity accurately in an observational study with the subjective endpoint of pain. and i would imagine a huge selection disadvantage if you look at those patients who had been put on opioids). the best ...

NEJM just released the 6 year followup of the of the ADVANCE trial, one of the big trials which led to a re-evaluation/relaxation of the targeted A1C goals for diabetic patients. there were 2 arms to the study, with patients randomized to intensive vs control regimens for A1c and for blood pressure control. the initial study (see  dm ADVANCE trial nejm 2008 in dropbox, or DOI: 10.1056/NEJMoa0802987) :     --​11140 patients with Type 2 diabetes randomized to standard vs intensive control with goal A1c of 6.5%, mean age 66, 43% female, average duration of diabetes 8 years, 32% with history of macrovascular disease, 10% with microvascular, baseline A1c was 7.5% (ie, a group with not-so-bad control to begin with). followed 5 years.     --patients assigned to intensive glucose control were given gliclazide modified release 30-120mg, with sequential addition/increase dose of metformin, then thiazolidinediones (TZD)...

the American Heart Assn and Am College of Cardiol (and endorsed by Am College of Sports Medicine) just published guidelines on EKG screening in healthy 12-25 year olds (see athletic screening ekg AHA 2014 in dropbox, or DOI: 10.1161/CIR.0000000000000025​). most of the data are from studies on screening young people in competitive athletic programs, with the goal to decrease sudden death, a rare but clearly bad outcome. as noted in prior blogs, there is a significant difference in the different recommendations: the European Society of Cardiol has recommended national EKG screening initiatives of athletes based on studies there (positive in Italian study, though not replicated in an Israeli one), but the AHA has consistently been against them (prior blogs have detailed the reasons, including the fact that the most common cause of athlete-associated sudden death in Veneto Italy, the site of the most positive intervention study, is from a specific genetic...

there have been several blogs i've sent out over the past couple of years on artificial sweeteners. one on 5/13/14 comments on studies showing they are associated with weight gain (though other studies refute this), that their intense sweetness may actually distort taste preferences leading people to eat higher sugar-content foods, and that they may actually increase glucose and insulin responses after a glucose meal. the journal Nature had a really striking article on these sweeteners and their effect on gut flora and glucose tolerance (see  microbiome artificial sweeteners nature 2014 in dropbox, or  doi.org/10.1038/nature13793 ). most of the non-caloric artificial sweeteners (NAS) pass through the gut without being absorbed, thereby being directly exposed to the gut microbiota (and prior blogs have shown that alterations of the gut microbiome have been associated with the metabolic syndrome). this Nature study had several components, with results:   ...

not-so-surprising article in NY times today highlighting both the remarkably high cost of electronic records (largely supported by public monies) and their remarkably poor performance (specifically in their ability to exchange information across different electronic records) -- see  http://www.nytimes.com/2014/10/01/business/digital-medical-records-become-common-but-sharing-remains-challenging.html?emc=edit_th_20141001&nl=todaysheadlines&nlid=67866768&_r=0 ​ . to me, it was folly to have the feds fund all of the different private electronic med records which meet some baseline functionality, both because of their exorbitant costs and the obvious issues of intercommunicability. especially since there is the remarkably functional (and free) VA system available to all. in fact, i saw a recent throw-away med journal (i think it was Medical Economics) which rated the different electronic records based on provider feedback, and of the 30 or so records, the VA...