geoffrey modest medical blogs

Very interesting article in BMJ on depression rx (See  depression resp to low intens interven bmj 2013  in dropbox), a meta-anal of 16 studies with 2470 pts. The standard of care in UK, per this article, is to stratify patients by degree of depression, and in those less severely depressed, provide "low intensity" psychological intervention, which is based on cognitive behavioral therapy but is provided through written materials or internet-delivered.  This is the first step of a stepped-care approach, which can step up to conventional high intensity intervention (12-16 therapy sessions of cognitive behav therap) if needed. However, the decision threshold of when to start with the low-intensity intervention is not so clear from the medical literature.  In this study/analysis, they looked at 2470 pts with depression. Turns out that some of these had moderate to severe depression and were still referred to the low-intensity group. And they followed the Beck Depression Inventory

NY Times piece on Sunday, see link below. Brings up several issues, including inappropriate incentives of fee-for-service system (leading to too many procedures, increased use of more expensive oncology meds), big pharma pushing remarkably expensive cancer drugs and some with very marginal benefit, and use of very expensive and largely unproved robotic surgery for cancer. See  http://opinionator.blogs.nytimes.com/2013/03/23/a-plan-to-fix-cancer-care/  .   Coincidentally, there was a strong editorial today in the boston globe (see  http://www.bostonglobe.com/lifestyle/health-wellness/2013/03/25/state-cautions-hospitals-about-patient-complications-during-robot-assisted-surgery/xOAsxR80qH5mVENDdktjKL/story.html?camp=newsletter  ) reporting that there is a Massachusetts health advisory about safety concerns with robotic surgery.  So, while hospitals had been flashing their new sexy, seductive, high-tech (and remarkably expensive) devices to lure patients to them, now the brigham hosp

a population-based cohort study published this week in the annals of internal medicine compared treatment with chlorthalidone and hydrochlorothiazide for htn in older adults (see   htn chlorthal vs hctz elderly aim 201 3  in dropbox).  canadian study of 30K patients, assessing death or hosp for chf, stroke or MI. the 30K patients were from a database of 1.1M pts on either of these drugs (ie, this study was data-mining from prescriptions written, hospitalizations, and a few demographics).  mean age and median followup of about 1 year. mean dose of chlorthal was 27.3mg and hctz was 18.3.  results: -no diff in primary outcome (3.2 vs 3.4/100 person-yrs) for chlorthal vs hctz -hosp for hypokalemia (hazard ratio of 3) or hyponatremia (HR 1.7) -when compare hospitalizations for hypokalemia and compare similar doses of chlorthal and hctz, only achieves significance with the 25mg dose (HR 2.2) and the 50mg dose (HR 5.5).  the 12.5 mg dose had a trend with chlorthal doing better. [in t

BMJ did a recent meta-anal of b-blockers in pts with chf with decreased ejection fraction. 21 studies with 23K pts, median age 61, 77% men, median LVEF 25%, analyzing data on different b-blockers (most studies with carvedilol), followed median 12 months, assessing primary endpoint of all-cause death ( see   chf bblockers reduced EF metaanal bmj 2013   in dropbox ).  overall conclusion  was that there was not much difference between the  many b-blockers  analyzed (carvedilol, atenolol, metoprolol, bucindilol, bisoprolol or nebivolol), with average RR 0.69 (ie, 31% reduction). a few points: --generic b-blockers (eg carvedilol, metoprolol, bisoprolol) have the best data (  there was  only one study with atenolol, though  it was  no t  statistically significant differen t from  any of the ones tested) --carvedilol had the best (not statistically significant) decrease in mortality (40%) with absolute risk reduction of 6.6%. perhaps attrib to its effects as antioxidant, improving endoth

N EJM with recent study of sciatica and MRI (see  low back pain mri after 1 yr unhelpful nejm 2013   in dropbox) .  followup on previously reported study, the Leiden-The Hague spine intervention prognostic study group (see  lbp sciatica surgery vs med nejm 2007 in dropbox), which assessed 283 people with sciatica for 6-12 weeks and MRI showing nerve root impingement correlating with sx, randomized pts to early surgery vs medical management, finding that improvement was faster with early surgery, but no diff in results after 1 year.  they then did repeat MRI after 1 year, when postop fibrosis should have stabilized, and compared MRI findings to clinical outcomes.  results:     - 84% overall had favorable clinical outcomes (complete or near complete disappearance of sx at one year), with  85% of those with disc herniation had a favorable outcome and 83% without disc herniation had a favorable outcome (ie, no difference) - disc herniation was found in 35% of pts with favorable outc

Recent article in Pediatrics (see  pertussis immunity waning peds 2013  in dropbox), with large cohort of kids (400K) who had complete immunizations with Dtap (5 shots, last dose between 4-6 years old) and looked at cases of pertusis in relation to timing of last shot.  Looked at 2 states (Minnesotta and Oregon).  1 year after the last Dtap, the rate of pertussis/100K kids was 15.6 in minnesota and 6.2 in oregon.  6 years after, it was 138.4 and 24.4, respectively, in those states.   This is consistent with the new recommendation by cdc to give pertussis vaccine (eg Tdap) to all women late in pregnacy for each pregnancy (they cite that there is sufficient decrease in antibody titer within months of immunization that passive placental transfer to the newborns might be insufficient if given too early). There are differences in the dosages of detoxified pertussis toxin between the kid and adult formulations (DtaP for kids has 10 mcg of pertussis toxin, Tdap for adults has 2.5 mcg), a

review of frailty in elderly in the recent lancet (see  geriatrics frailty lancet 2013  in dropbox). a bit hard to define  frailty , but mostly has to do with increased vulnerability, with disproportionately large changes from small insults (eg new drugs, minor infections). seems to be an accumulation of molecular and cellular damage from many mechanisms over time.  one recent study found that in assessing 12 measures of dysfunction in 6 different systems ,  abnormal results in 3 or more systems was more predictive of frailty, and, specifically, the number of abnormal systems was more predictive than abnormalities in any particular system (i have seen several older people with small, potentially reversible problems in several different  organ  systems -- a little heart failure, renal dysfunction, infection  --  and i anticipated being able to fix each one, but with the multi-system issues in aggregate the patients have done poorly). so, a few issues in the article. --frequent clinica

Annals with article on antimicromial resistance of GC, comparing men who have sex with men MSM vs men who have sex exclusively with women MSW (see  GC in msm resistance annals 2013  in dropbox).  CDC sponsored surveillance study of 35K men with symptomatic GC over 6 year period. From 30 STD clinics throughout US.   --in all US regions except West, MSM signif more likely to have GC resistant to ceftriax and azithro (elevated MICs, which suggest emerging resistance) than MSW. Also high prevalence of actual                                             resistance to cipro, penicillin and tetracycline.  For our region (Northeast and South):   -- Emerging resistance (expressed as odds ratio comparing MSM vs MSW):         azithro 3.7         cefixime 33.1         ceftriax 3.6         multidrug 36.4 --endemic resistance         cipro 2.5         penicillins 2.3         tetracycline 2.1   So, pretty bad news.  Clear that cefixime is pretty useless....  Major points a

one important issue to keep in mind is the difference between community data (eg, risk of cardiovasc dz) through predictive models such as the framingham risk score (FRS) and the actual risk of an individual (eg, by looking at actual disease present).  although the community risk scores are important for us to improve modifiable risks, we all have seen patients at remarkably high risk who have no evidence of heart dz (eg clean coronaries) for example.  there have been several models looking at the individual's risk, including ankle-brachial indices or carotid intima-media thickness (see below). in addition, CAC (coronary artery calcification) has been shown in several studies to correlate strongly with actual heart disease. in this light, recent study (see   stroke cac predictor stroke 2013  in dropbox) of 4200 subjects in Germany aged 45-75, 47% men and without prior stroke, CHD, or MI were evaluated for development of stroke using CAC as well as more traditional risk factors of

there have been a slew of articles recently on calcium and vitamin D.  i will review several of them. but, be forewarned, there are lots of articles out there which come to pretty strikingly different conclusions 1.  new recommendations from US prevent services taskforce on vit d and calcium to prevent fractures in adults (see   vit d calc recs uspstf 2013  in the dropbox). basic conclusion is that  -there is insufficient evidence to assess benefits/harms of vit d/calc supplementation in preventing fractures for premenopausal women and men - there is insufficient evidence to assess benefits/harms of daily supplementation with greater than 400 IU vit D3 and greater than 1000 mg calcium for primary prevention of fracture in noninstitutionalized postmenopausal women -recommends against daily supplementation with <= 400 IU of vit D3 and <=1000mg of calcium  for primary prevention of fracture in noninstitutionalized postmenopausal women (note double-negative)   -prior r