geoffrey modest medical blogs

there are 2 potentially very serious bacterial infections, both with functional vaccines available but not previously recommended, that seem to be more common in HIV infected patients: HIB (haemophilus influenzae type B) and meningococcus. T he Advisory Committee on Immunization Practices, ACIP,  ​ just came out with recommendations to immunize HIV-positive patients against meningococcus. details: 1. for the HIB infection: i had been immunizing all HIV patients with HIB vaccine until a few years ago, based on a case-control study about 20 years ago showing a higher prevalence of invasive HIB infections in HIV positive patients. Though the data on efficacy were lacking, it seemed to me that the potential benefit far outweighed the very low risk of this tried-and-true vaccine. The current feeling, from my reading, is that while HIV may be a risk factor for invasive HIB infections, the incidence of HIB infections overall has plummeted due...

Another really interesting study was published on the benefit of placebo, this time in decreasing chronic low back pain (see  lbp placebo pain2016 in dropbox, or doi: 10.1097/j.pain.0000000000000700 ). This study was remarkable in that both the clinicians and the patients were aware that the intervention was placebo vs their current care. Details: --83 patients (of a total of 243 screened) with chronic low back pain (LBP) for at least 3 months duration were randomized to open-label placebo (OLP) vs treatment as usual (TAU) for 3 weeks. The latter group was told that they would be offered the opportunity to take the placebo pills after the 3 week intervention. --exclusion criteria included taking opioids --mean age 44, 71% women, 74% employed, 87% used pain meds in past week (76% NSAIDs/analgesics, 22% antidepressants, 15% benzos, 40% adjuvants of cyclobenzaprine/gabapentin/thiocolchicoside, 14% complementary medicine). --pain severity assessed in three 0-1...

A recent study of older community-dwelling high-risk hypertensive patients looked at the relationship between their achieved blood pressure and cardiovascular outcomes ( see  htn automated office bp in ontario hypertension2016  in dropbox, or Myers MG Hypertension. 2016;68:866​). details: --6183 community-dwelling Ontario residents >65yo on antihypertensive therapy, followed mean of 4.6 years (the CHAP study: Cardiovascular Health Awareness Program) --blood pressure measured (as in the SPRINT trial) by AOBP (electronic automated office blood pressure). In Ontario, the protocol was that the person rest seated in a quiet place, undisturbed before and during the readings. The research staff did not speak to the subjects or interact with them. The patient did not wait 5 minutes, but the AOBP recorded the blood pressure each minute for 5 minutes and computed the mean value. The AOBP was recorded in community pharmacies, which a different study fou...

T here was an interesting subgroup analysis of the ACCORD blood pressure wing (Action to Control Cardiovascular Risk in Diabetes) which found that those with orthostatic hypotension (OH) had a significantly higher risk of mortality and heart failure events (see  hypotension orthostatic ACCORD hypertension2016  in dropbox, or Fleg JL, Hypertension. 2016;68:888 ). Details: -- the ACCORD trial had 10,251 high-risk patients with type 2 diabetes, hemoglobin A1c >7.5%, and were between 40 and 79 years old with cardiovascular disease or 55 to 79 years with anatomic evidence of subclinical atherosclerosis, albuminurea, LVH, or >= 2 additional cardiovascular risk factors. 4733 were randomly assigned to intensive vs standard blood pressure control in a non-blinded trial, with target systolic blood pressure (SBP) of <120 vs <140 mm Hg, and with no requirements as to what medications to give (clinicians' decisions) -- 4266 partici...

 given the recent 2 articles on cervical cancer screening, I thought I would add (briefly) a third to the troika (s ee  pap in women with HPV vaccine jnci2016   in   dropbox , or  doi :  10.1093/ jnci /djw216). Funded by National Cancer Institute of the NIH and done by Harvard School of Public Health. details: --this is a mathematical modeling of the cost-effectiveness of different cervical cancer screening approaches in HPV-vaccinated women --they looked at different levels of cost-effectiveness thresholds: from $50K to $200K per quality-adjusted life-year (QALY) gained results: -- in women who were fully vaccinated with either the bivalent or quadrivalent HPV vaccine , optimal screening strategies involved either cytology or HPV screening alone every 5 years starting at age 25 or 30 (cost-effectiveness ratios ranging from $34,680 to $138,560 per QALY gained --in women vaccinated with the nonavalent vaccine (tha...

There was a recent systematic review and network meta-analysis of treatments of H Pylori infections in countries with high vs low clarithromycin resistance (see  hpylori rx network metaanal gut2016  in dropbox, or doi:10.1136/gutjnl-2016-311868). A network meta-analysis is helpful when there are not head-to-head comparisons of all of the therapies, using mathematical  assumptions/ manipulations to approximate results across studies in an attempt to approximate the likely results if there were such direct  comparisons .  There was another recent blog which did a similar analysis of H pylori treatments but was not stratified by clarithromycin sensitivity (see  http://gmodestmedblogs.blogspot.com/2015/08/h-pylori-regimens.html    from the BMJ in 2015). details of the current analysis: --117 trials with 32,852 patients analyzing 17 H pylori eradication regimens were included --mean age 48, trials ranged f...