geoffrey modest medical blogs

for those of us either treating patients with chronic kidney disease or following them for other reasons, there was an important article in lancet which found that calcium-based phosphate binders are associated with increased mortality  (see  chr kidney dz and phosphate binders lancet 2013  in dropbox, or  http://dx.doi.org/10.1016/ S0140-6736(13)60897-1).  this was a meta-anal of 5 new RCTs and 9 older ones  from a previous meta-anal, with 11 reporting mortality as an outcome. 4622 pts involved. compared those on calcium-based phosphate binders (calcium carbonate or calcium acetate) with non-calcium based binders (sevelamer hydrocholride or carbonate -- brand name eg of renagel -- or lanthanum carbonate -- brand name fosrenol). results:     --overall 22% reduction in all-cause mortality with non-calcium based phosphate binders.  most studies in dialysis patients, b ut the few with predialysis (only 134 patients) with almost significant 46% decrease in all-cause mortality (0.28-1.

the whole issue of e-cigarettes is pretty confusing. several of my patients have been using them with pretty significant cigarette quit rates even after stopping the e-cigarette. one of my patients brought in one (a BLU, as i remember), asking me what it contained.  after thoroughly scouring the e-cigarette and packaging, i could find no indication of what was inside the cigarette. there were a couple of articles that helped clarify the situation. 1. recent randomized controlled trial in lancet from new zealand. 657 adult smokers averaging 18 cigarettes/d randomized to 16mg e-cigarettes, 21mg nicotine patch, or placebo e-cigarette (no nicotine), beginning one week before quit date. only low intensity support provided -- voluntary telephone counseling.  (see  smoking ecigarettes lancet 2013  in dropbox, or  http://dx.doi.org/10.1016/ S0140-6736(13)61842-5). verified abstinence after 6 months:     --7.3% with nicotine e-cigarettes     --5.8% with patches     --4.1% with plac

The question arises occasionally as to whether there is an advantage of dual blockade of the renin angiotensin system, especially in cases of patients with heart failure or severe proteinuria.  The rationale of dual blockade is that ACE inhibitors by themselves lead to incomplete and often transient RAS blockade in most patients because of a physiologic escape mechanism/alternative pathway, and the objectives of RAS blockade are to decrease cardiac remodeling, reduce endothelial dysfunction, and decrease renal dysfunction by decreasing   the  putative nephrotoxic effects of severe proteinuria.  Dual blockade has been mostly achieved through the combination of an ACE inhibitor and an angiotensin receptor blocker (ARB), or the combination of an ARB/ACE-I with the direct renin inhibitor aliskiren.  There was meta-analysis in the BMJ recently of 33 randomized controlled trials with 68K patients with a mean age of 61 and followed a mean of 52 weeks  (see  chf dual RAS blockade bmj 2013  i

nongluten G Geoff A. Modest, M.D.     Reply all | Mon 10/28/2013, 1:54 PM Geoff A. Modest, M.D. You forwarded this message on 12/2/2015 7:15 PM It is not uncommon to see patients who have typical symptoms of celiac disease who seem to respond to a gluten-free diet but have negative workup for celiac disease. These patients are said to have nonceliac gluten sensitivity (NCGS), which is characterized by irritable bowel-type symptoms after the ingestion of gluten, improvement after gluten withdrawal from the diet, and negative celiac serologies/biopsies. they can have both intestinal sx (diarrhea, abd discomfort/pain, bloating, flatulence) and extra-abdominal ones (headache, lethargy, poor concentration, ataxia, oral ulceration). Additionally (and previously unknown to me), there are some food items which can also cause these symptoms, called FODMAPs (fermentable, oligo-, d

in one of my precepting sessions, the question came up about the utility of finasteride as well as the predictive accuracy of PSA screening.  finasteride does do well in decreasing prostate volume, though it takes months to work. but i wanted to circulate 2 important articles (both from the prostate cancer prevention trial), which i think sheds light on these issues. 1. prostate cancer prevention trial (see  prostate ca prevention trial nejm 2003  in dropbox) -- 7 year study of 19K men >55yo, with PSA <3 and nl DRE, randomized to finasteride 5mg/d vs placebo. rationale of study is high prevalence of prostate cancer in men (17% lifetime risk). found that prostate cancer was reduced by the prophylactic administration of finasteride by 25% (24% in the placebo group, and 18% with finasteride). BUT, higher incidence of high-grade prostate cancer (Gleason scores 7-10) in the finasteride group (6.4%) vs the placebo group (5.1%).  also sexual side-effects of finasteride. but, bottom l

There have been a couple of articles of note on prostate cancer and screening.    One was in this week's New England Journal of Medicine (see  prostate ca inc use of radiotherapy nejm 2013  in dropbox, or DOI: 10.1056/NEJMsa1201141). The impetus for the study was to determine if urologists purchasing their own office-based, expensive intensity-modulated radiation therapy (IMRT) equipment were more likely to use this form of radiation therapy vs urologists who do not own the equipment.  The researcher looked at Medicare claims from 2005 through 2010 in 2 samples: 1 was in private practice groups with 35 urologists self-referring for IMRT who started using this equipment during this time period versus 35 groups not owning this therapy; the other study was of a group of 11 non-self-referring urologists at National Comprehensive Cancer Network centers compared to 11 self-referring urology groups in private practice.  The intention of the second study was to compare urologists who

There have been a slew of articles in the literature in the past year on the harmful effects of statins. A recent study-level network meta-analysis was reported, incorporating 135 randomized controlled trials with 250K participants to assess the reported adverse effects (note that some of these effects could have been under-reported, such as myalgias, given the relative frequency of such in many of our clinical practices but their low numbers) -- see  statin tolerability circ cardiol qual 2013  in dropbox, or DOI: 10.1161/CIRCOUTCOMES.111.000071.   The findings:                 --no difference between individual statins and controls for: myalgias (subjective muscle pain), creatine kinase elevations (varied in studies from 3x to 10x more than baseline), cancer, or discontinuations because of adverse events. Likelihood of rhabdomyolysis small and no diff from controls.                 --overall 9% higher likelihood of developing diabetes                 --51% higher likelihood o

endocrine society and am assn of clinical endocrinologists added their suggestions to the choosing wisely website (see  http://www.choosingwisely.org/doctor-patient-lists/the-endocrine-society-and-american-association-of-clinical-endocrinologists/  , or   choosing wisely endocrine 2013  in dropbox). this website in general has suggestions about unnecessary tests from many of the major specialty and primary care organizations and is really well-organized.   the endocrine society points:   avoid routine daily self-glucose monitoring in adults with stable DM2 or agents not causing hypoglycemia (eg metformin).  The issue here is that it does not make sense to have patients check their fingersticks more than once a day if they are well-controlled.  There was a study in BMJ a couple of years ago suggesting that glucose self-monitoring in the aggregate did not change diabetes management, largely because physicians did not act on that information.  However, I do find there is an addit

there seems to be several recent recommendations suggesting higher BP goals than JNC7.  the american diabetes assn set the new goal at 140/80, given the results of the ACCORD trial. the european society of cardiology came out with guidelines which i sent out before  (see  htn guidelines european soc htn 2013  in dropbox, or doi:10.1093/eurheartj/eht151 ) , which in brief set their goals as:     -- systolic bp < 140 in patients with low-to-mod cardiovasc risk and those with diabetes (best data) as well as those with hx stroke/TIA, coronary art dz, diabetic or nondiabetic chronic kidney dz, without differentiating the presence of proteinuria (less good data)      --in elderly <80yo with SBP >160, decrease  SBP  to 140-150 range     --in fit elderly <80, SBP <140 should be considered (though i would add to check orthostatics in elderly esp with the lower goal, as well as checking symptoms). in fragile elderly, individualize goal     --in elderly >80yo and SBP>

the american heart association published a position paper focusing on lifestyle interventions to prevent heart disease ( see  cad lifestyle change circulation 2103  in dropbox, or go to   http://circ.ahajournals.org/content/early/2013/10/07/01.cir.0000435173.25936.e1.citation  ).  they note:     --  there is abundant evidence that the risk of heart disease is much lower in those with better cardiovascular health metrics (nonsmoking, good diet, physical activity, normal BMI, normal BP, optimal lipids and normal fasting glucose):  78% less heart disease over 5.8 years in those with 5 or more of the above compared to those with none, with similar numbers in longer term studies      --younger adults with healthy behaviors track to having lower biological risk as they age.     -- those with initially poorer health behaviors who can change them do better clinically.      -- health care providers, even with brief interventions, are able to help patients quit smoking, improve their

in recent study looked at factors which might distinguish cardiac syncope from vasovagal syncope in children up to 18 years old (see  syncope in kids j peds 2013  in dropbox, or http://dx.doi.org/10.1016/j.jpeds.2013.07.023  ).  the study was set in a pediatric cardiology clinic including 89 patients who had vasovagal syncope over a one year period, compared with children with known cardiac syncope (given the relative rarity of cardiac syncope, they searched their files and found 17 patients who had significant cardiac disease and syncope).  8 with cardiac syncope had long QT syndrome, 3 had cardiomyopathy (2 HOCM), and one of each had  left coronary artery originating from the right aortic cusp, primary pulmonary hypertension, myocarditis with ventricular tachycardia, catecholaminergic polymorphic ventricular tachycardia, cardiac fibroma, and idiopathic ventricular tachycardia (notably, no Brugada or arrhythmogenic right ventricular dysplasia). results (only statistically significant

Recent recommendations by the Am College of Chest Physicians to perform low-dose CT screening of smokers (see lung cancer CT screening guidelines chest 2013 in dropbox, or DOI: 10.1378/chest.12-2377 ). these recommendations parallel the interim recommendations of the American Lung Association (see lung cancer CT screening guidelines ALA 2012 in dropbox) Baseline: lung cancer is common and has generally poor prognosis (esp with lesions greater than stage 1), causing as many deaths as the combo of the next four cancers. one thing to keep in mind is that there are newer therapies that work better than the old ones -- targeted to the specific tumor-associated genetic mutations engendered by the cancer (ie, possible that these new treatments could change the risk/benefit analysis of screening in the future).  of note, the arena of smoking-related morbidity is changing: tobacco companies have seen shrinking local markets (showing that sometimes after decades of obvious connection wit

recent online article in BMJ finding lack of efficacy of antibiotics or ibuprofen on acute bronchitis with discolored sputum  (see  bronchitis and antibiotics bmj 2013  in dropbox, or BMJ 2013;347:f5762 doi: 10.1136/bmj.f5762). 416 adults aged 18-70 in primary care centers in spain with sx of respiratory tract infection of less than 1 week, cough predominant with discolored sputum, and at least one other sx suggesting lower resp tract infection (dyspnea, wheezing, chest discomfort or pain). chest xray not required to r/o pneumonia -- the dx of acute bronchitis was a clinical one. randomized to ibuprofen 600 TID, amox/clavulanic acid 500/125 TID, or placebo for 10 days.  patients reported sx in diary. overall, 40% of patients were smokers, 10% had diabetes, 8% with fever, >50% had increased CRP with 25% quite high CRP (>21). results     --median # days from the initial presentation of frequent cough slightly decreased with ibuprofen (9 days) vs those on abx (11 days) or place

There is a study in the recent issue of the Lancet assessing the role of anti-retroviral therapy to prevent HIV transmission in sero-discordant couples in China.  This was an observational, retrospective study of almost 40,000 discordant couples with over 100,000 person years of followup.  China was adhering to the general WHO guidelines of initiating retroviral therapy in people with CD4 counts of 350 or less.  Their level of HIV transmission was compared to HIV discordant couples in which the HIV positive person had higher CD4 counts and were not on therapy.  (see   hiv treatment as prevention china lancet 2013   in dropbox,   or   http://dx.doi.org/10.1016/S0140-6736(12)61898-4 ) .  Couples with inadequate followup visits were excluded from analysis.  Treated patients were older than non-treated patients.  Patients were followed up to 8 years, though the median duration of followup was only 1.2 years for non-treated couples and 2.4 years in those on therapy.  Results: