geoffrey modest medical blogs

A large VA study found that overall cancer risk decreased with improved HIV viral suppression, but an increased residual risk remained (s ee  hiv cancer dec still elevated AIM2018 in dropbox, or doi:10.7326/M16-2094 Details: --42,441 HIV-positive veterans were compared to 104,712 demographically matched uninfected veterans, from 1999-2015 -- 64% were 40-60 years old, 98% male, 40% non-Hispanic white/50% non-Hispanic black/9% Hispanic, 67% ever-smokers/27% never-smokers, 35% alcohol use disorder, 63% HCV negative/ 15% chronic HCV, 75% diabetes -- comparing the groups: similar distribution of age, sex, race/ethnicity, smoking status, alcohol use. Those with HIV had more chronic hepatitis C and a lower prevalence of diabetes -- HIV control: 22% unsuppressed (suppression defined as < 500 copies/mL), 27% early suppression (initial period up to 2 years of continuous suppressed observation time, but also includes those who were suppressed but then became unsuppressed...

​​ A recent article found a significant increase in cancers, years after exposure to low-dose ionizing radiation in adults with congenital heart disease (see radiation exp kids and malignancy circ2018 in dropbox, or DOI: 10.1161/CIRCULATIONAHA.117.029138) Details: --24,833 adults with congenital heart disease (CHD) in the Quebec Congenital Heart Disease Database, aged 18-64, from 1995-2009, with 250,791 person-years of follow-up. Those with genetic disorders were excluded --12% severe CHD (cyanosis at birth, or requiring early surgical intervention (such as tetralogy of  Fallot , truncus arteriosus, transposition complex,  univentricular  heart), 62% shunt (ASF, VSD, PDA, coarc); 25% valvular abnormalities --median age 54, 44% male, comorbidities: 15% heart failure/15% atrial arrhythmias/8% CAD/6% PAD/10% DM/33% hypertension/15% obesity/8% hyperlipidemia/12% CHD surgery/20% all cardiac surgery --patients with cancer were older and had more cardia...

A recent systematic review and meta-analysis confirmed a mortality benefit by aldosterone antagonists in patients with an ST-segment elevation MI (STEMI ) without heart failure (s ee  MI aldost antag in STEMI jamaintmed2018  in dropbox, or doi:10.1001/jamainternmed.2018.0850 ​). Details: -- 10 international RCTs were included, with a total of 4147 unique patients who had STEMI without heart failure. -- The studies are in general quite short, only 2 had follow-up for one year. Others were 6 months or less -- all patients had initial treatment with a percutaneous coronary intervention (PCI) or thrombolysis -- Main outcomes: mortality, MI, new CHF, ventricular arrhythmias, change in left ventricular ejection fraction (LVEF), serum creatinine level, and potassium levels Results: -- comparing the use of aldosterone antagonist vs control:     -- 38% decreased mortality, 2.4% vs 3.9%, OR 0.62 (0.42-0.91), p=0.01    ...

​The CDC just had yet another advisory. This time on outbreaks of hepatitis A in multiple states (see https://emergency.cdc.gov/han/han00412.asp ). Details: --from Jan 2017 to April 2018, there were >2,500 reports of hepatitis A virus (HAV) infections associated with person-to-person transmission in several states in the US --for >1900 of them, risk factors were known: >1300 (68%) reported drug use (injection on non-injection), homelessness or both. --in the 1980's, drug use was a risk factor in >20% of HAV infections per the CDC, but no large outbreaks since adoption of vaccine recommendations in 1996 --from the recent outbreaks:     --California 2018: 704 cases, 461 hospitalizations, 21 deaths: majority homeless or using illicit drugs in setting of limited sanitation     --Kentucky 2017-18: 445 cases, 6 deaths: 3% homeless, 68% illicity drug use, 17% both, <1% MSM, 21% no known risk factors ...

A recent article documented the emergence of potentially epidemic, highly resistant strains of Salmonella typhi, the organism associated with typhoid fever (see  http://mbio.asm.org/content/9/1/e00105-18.full.pdf ​ ). Thanks to Paul Susman for bringing this to my attention. Details : -- there was an outbreak in Hyderabad, Pakistan of more than 300 cases of extensively drug-resistant (XDR) typhoid in a 10 month period between 2016 and 2017. -- Prior reports have documented relatively common resistance to the three first-line antibiotics (chloramphenicol, ampicillin, and trimethoprim/sulfamethoxazole), a multidrug resistant (MDR) organism prevalent in parts of South and Southeast Asia, Africa, and Oceania since the late 1970s. -- This new XDR strain is now also resistant to fluoroquinolones and third-generation cephalosporins (those typically used were parenteral ceftriaxone and cefotaxime, as well as oral cefixime) -- previously, there have been just sporadic c...

​A recent analysis of a Hong Kong database found that older individuals receiving clarithromycin-based H. pylori eradication had a lower risk of gastric cancer (see  h pylori treatment dec gastric ca older pts gastro2016  in dropbox, or  doi:   https://doi.org/10.1053/j.gastro.2018.03.028 ) Details: -- 73,237 subjects were identified in the Hospital Authority database of Hong Kong who had H. pylori infections and received a course of triple therapy for H. pylori eradication that contained clarithromycin. -- H. pylori testing is not routinely performed in Hong Kong unless there are dyspeptic symptoms or upper endoscopy is performed for other reasons. -- mean age 55 at the time of H. pylori treatment, 47% male, history of peptic ulcer in 5%, upper endoscopy diagnosed H. pylori in 83%, diabetes 13%/hypertension 22%/dyslipidemia 9%/ischemic heart disease 10% -- 13.4% needed retreatment for H. pylori, defined as having a subsequent prescription of an...

There has been a pretty shocking increase in both gonorrhea and syphilis cases in the past 20 years in Massachusetts (see file:///C:/Users/geoff/Downloads/MDPH%20DSTDP%20ClinAdv%20SyphGCIncr%20FINAL%2023Apr2018.pdf ) -- In the 1990s, the number of cases of infectious syphilis had decreased to about 100 per year, now is at more than 1000 -- similarly the number of cases of gonorrhea decreased to approximately 2000 per year and is now well over 7000. -- In addition there have been increasing reports of serious complications:     -- syphilis: ocular, otologic, other forms of neurosyphilis, syphilitic aortitis, congenital syphilis     -- gonorrhea: including gonococcal ophthalmia neonatorum -- MSM have a disproportionately higher burden of these infections, 75% of infectious syphilis and 21% gonorrhea cases -- women of childbearing age are also having more infections, 5% of syphilis and 30% gonorrhea recommendations: -- screen more a...

A community-based cohort study confirmed that metformin was safe to use down to an  eGFR  of 30 (see  dm   metf   ckd  jamaintmed2018  in dropbox, or  doi:10.1001/jamainternmed.2018.0292 ). Details: --75,413 patients with diabetes within the  Geisinger  Health System, from 2004-2017; results replicated in 67,578 new metformin users and 14,439 new sulfonylurea users from 2010 (the "active comparator" group, also from Geisinger) and  from 350 private US health systems (replication cohort) --primary cohort ( Geisinger ): mean age 69, 51% female, 97% white, BMI 34, hypertension 69%/ cardiovasc  disease 12%, heart failure 10%, mean sodium bicarb 27, A1c 7.4 --meds: insulin 17%, statin 43%, RAS inhibitor 47%, diuretics 34%, NSAIDs 21% --primary outcome: association between metformin use and hospitalization for acidosis, stratified by  eGFR --of the 75,413 patients:     --14,662 had...