geoffrey modest medical blogs

There have been several articles recently on non-alcoholic fatty liver disease (NAFLD) in a recent special issue of the journal Digestive Diseases and Sciences, as well as a recent release of NAFLD clinical management guidelines by the European Assn for the study of NAFLD. Since NAFLD is so common throughout the world, since it is amenable to lifestyle interventions, and since there was so much interesting info on NAFLD but so many unresolved questions, I will devote 3 blogs to this: 1.       Natural history of NAFLD 2.       Review of therapies, with more detail on a couple of topics (eg the role of the microbiome and of specific dietary components, esp fructose) 3.       A review of the EASL guidelines for NAFLD ---------------------------------------------------------------------------------------------------------------------------------------------------------- NAFL...

See the response below to recent blog:  https://gmodestmedblogs.blogspot.com/2018/08/uspstf-does-not-back-lipid-screening-in.html   , sent around with Holly’s permission. Her study (hyperlink below) in 3 sets of adolescents/young adults aged 17-21 and their parents (including some with familial hypercholesterolemia, obesity, and generally healthy) posited different cholesterol screening scenarios, finding that in each of these 3 groups, both the adolescents and the parents saw worse cholesterol results as signifying poorer health, with several commenting about the need to change their lifestyles. This provides support for universal cholesterol screening and using the results to try to influence behavior.  Even in adolescents. geoff ___________________________________________ Awesome summary Geoff about an issue near and dear to my heart (pun intended!). I am interested in whether knowing about heart health/heart disease risk changes teens behavior.  P...

t here was a useful editorial detailing the indications for long-term proton-pump inhibitor use  (see  ppi harms benefits AmJGastro2016 ​ in dropbox, or Laine L. Am J Gastroenterol 2016; 111:913). As many of you know from prior blogs, I have been very concerned that many patients are on long-term PPIs because: they work; when patients are doing better on them, we can move on to address other issues; changing them involves somewhat detailed/time-consuming discussions with patients (detracting from focusing on the other issues); changing them may not work, so we might be back to square-one; when patients see GI specialists, they are uniformly put on PPIs (at least in my experience); and, despite GI specialty recommendations to step-down therapy from PPIs to H2-blockers or antacids, studies show that this rarely happens.  this review focuses on the indications for long-term PPIs, with little attention to the harms, but my guess is that most...

A new study looked at a large number of patients with chronic hepatitis B (CHB) who were on a statin, finding improved hep B outcomes (see  statin hepatitis B AmJGastro2016​  in dropbox, or Huang Y. Am J Gasstroenterol 2016). This blog follows a recent one I sent out: see  http://gmodestmedblogs.blogspot.com/2016/05/use-of-statins-in-patients-with.html    , which reviewed a recent study showing statin benefit in those with hepatitis c, also comments on the benefit of statins in NAFLD, and mentions that the data on hep B is more mixed. Details of the current study from Taiwan, where 15-20% of the population has CHB, half of which is by perinatal transmission: --population-based cohort study in Taiwan, with 298,761 patients with chronic hepatitis B (but without concomitant hep C, biliary cirrhosis, or alcoholic liver disease) and 6,543 on statins --mean age 50, 53% male, 5 year follow-up on cirrhosis and same for decompensated cirrhosis, more...

There have been many studies finding that poverty or living in poorer neighborhoods is associated with increased morbidity or mortality. However, it is hard to dissociate the array of potential risk factors associated with poverty to validate a true association (for example, do those with more morbidities overall tend to move to poorer neighborhoods since their income tends to be lower, etc ("social drift") – so that the association is really with the burden of increased morbidities?). In this light, a quasi-experimental situation existed in Sweden finding that those refugees assigned to poorer neighborhoods had more diabetes (S ee  dm  risk deprivation lancetendo2016  in  dropbox , or White JS. Lancet Diabetes Endocrinol 2016; 4: 517) . Details: --61,386 refugees aged 25-50, who arrived in Sweden from 1987-91, were assigned to one of 4833 different neighborhoods in a quasi-random fashion (90% of all refugees were randomly assigned. Those reuniting with family mem...

As many of you know based on my prior blogs, I have largely switched from using insulin to prescribing a GLP-1 agonist as my second line treatment for diabetes, after metformin (though I still use the short-acting sulfonylurea glipizide after metformin in patients who decline injection therapy, then try to use a GLP-1 agonist as the next step). A recent blog (see  http://gmodestmedblogs.blogspot.com/2016/06/liraglutide-decreases-cardiovascular.html   ) looked at using  liraglutide  vs placebo in older diabetic patients at high risk of cardiovascular events, finding that the GLP-1 agonist lowered A1c by 0.4 percentage points (the other meds were increased in the placebo wing to narrow the A1c gap), was associated with more weight loss, and had a 15% mortality benefit as well as a 22% decrease in major cardiovascular events, with benefit evident within 12-18 months. A recent retrospective review of the UK Health Improvement Network (10.5 milli...

I just received a comment from the USPSTF (see below) suggesting that there was an inaccuracy in how their diabetes screening  recommendation was  presented in my recent blog  http://gmodestmedblogs.blogspot.com/2016/07/uspstf-diabetes-screening-misses-most.html    . This blog reviewed a PLoS article which found that a majority of patients with dysglycemia (glucose intolerance or diabetes) would be missed if we followed the USPSTF recommendations. The gist of the USPSTF concern was that the original PLoS article and I only included their formal  recommendation summary, which indeed was included accurately (ie, " The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese", and was given a grade "B" recommendation ), but not the full content of their recommendation as outlined in their text. In general, whe...