geoffrey modest medical blogs

background: stroke is common, but 20-40% of strokes and 50% of TIAs have no evident cause after work-up (called "cryptogenic"). since afib is a common and treatable cause of stroke (and the treatment of afib with anticoagulants is different from that of other strokes with antiplatelet agents), and since those with untreated afib have higher likelihood of recurrent stroke, it seems reasonable to look hard for afib. 2 recent articles in NEJM tried to assess this -- the CRYSTAL AF trial (see  stroke and cryptogenic afib1 nejm2014  in dropbox, or DOI: 10.1056/NEJMoa1313600) was an RCT of 441 patients >40yo (mean age 61.5) with cryptogenic stroke in prior 90 days (negative workup including 24-hr Holter) randomized to a long-term insertable cardiac monitor (ICM) vs conventional followup. primary endpoint was time to first detection of afib lasting >30 sec within 6 months. secondary endpt was time to first detection of afib within 12 months.   Mean baseline  C HADS2 score

​interesting article on adolescents in the new york times (see  http://www.nytimes.com/2014/06/29/opinion/sunday/why-teenagers-act-crazy.html?ref=todayspaper  ). will review briefly:     --adolescent brain functions differently from adult brain         --the amygdala is highly developed (which governs the fear response)         --the prefrontal cortex is pretty underdeveloped (which provides reasoning and executive function), and remains so til the early-to-mid 20's         --the reward center is very developed --Implications         --with the highly developed reward center, teens tend to take lots of risks (the chase for rewards)         --but this is the time for increased issues around fears and anxiety (the amygdala issue) -- often the age when  anxiety disorder s ​ develop. teens have heightened fear responses, and in experiments tend not to extinguish these responses as easily as adults (ie, after repeated exposure). this raises issues, for example, of teens g

circulation just published article from sweden on profound effect of cessation of smokeless tobacco on post-MI mortality (see  smokeless tobacco cessation dec MI circ 2014  in dropbox, or DOI: 10.1161/CIRCULATIONAHA.113.007252). they assessed all patients who were <75 years old admitted to CCUs for MI between 2005-9 (the database included the vast majority of swedish hospitals). they followed patients for 2.1 years post-MI to assess the relative difference in mortality in the 675 who quit snus ( their form of oral snuff) vs 1799 who continued using. results:     --83 people died in the 2.1 years of follow-up     --mortality rate in those who quit snus was 9.7/1000 person-years;  mortality rate in those who continued snus was 18.7/1000 person-years     --adjusted for age and gender, the mortality rate HR was 0.51 (0.29-0.91) for quitters;  in multivariable-adjusted model, HR was 0.57 (0.32-1.02)     --these results were remarkably similar to those who quit smoking, with HR

the US prev services taskforce (USPSTF) updated their 2005 recommendation on abdominal aortic aneurysm (AAA) screening  (see  AAA screening USPSTF annals 2014  in dropbox, or doi:10.7326/M14-1204) .  bottom line: they recommend --     --"1-time screening for AAA with ultrasonography in men aged 65 to 75 who have ever smoked" (B  recommendation ) -- "ever-smoker" is anyone who has smoked >100 cigarettes in his/her lifetime     --"clinicians selectively offer screening for AAA in men aged 65 to 75 who have never smoked" (C  recommendation ) -- ie net benefit of screening is small, so assess medical history/risk factors (eg other vascular aneurysms, CAD, cerbrovasc disease, hypercholesterolemia, obesity, hypertension), family history of AAA, personal values. of note, reduced AAA risk in african-americans, latinos, and those with diabetes.     --"current evidence is insufficient to assess the balance of benefits and harms of screening for AAA

rather striking (and not surprising) article in MedPage Today about opioids. major issue is that the FDA commissioner is throwing around the statistic that 100 million americans are suffering from chronic pain (likely greatly exaggerated, per the article) -- and it was the  undertreating of chronic pain , by the way, which was the basis for the initial IOM (institute of medicine) in the 1990s report that led to the dramatic increase in opioid prescriptions. a new IOM report in 2011 brought up the 100M number (the link to the report is in the article -- see URL below). turns out that 9 of 19 experts on the IOM panel that issued the report "had connections to companies that manufacture narcotic painkillers", some receiving opioid company funding or were consultants to the drug companies. the IOM panel chair, phillip pizzo, is from stanford univ, which received "educational grants and research funding from companies that make pain treatments", and "10 months befor

editorial in the NY Times today (see  http://www.nytimes.com/2014/06/25/opinion/refusals-to-pay-high-drug-prices.html?ref=todayspaper&_r=0 ) notes the ability of pharmacy benefit managers, through their economic power with millions of customers, in fighting the high cost of meds. in general, Express Scripts, et al, are not covering very expensive meds (eg, Advair, Victoza, some cancer meds, etc) because of their high cost, and that this non-coverage has led to dramatic decreases in US drug sales (up to 30% range). the number of excluded drugs is increasing dramatically. as the editorial notes, the problem here is that it is the pharmacy benefit managers choosing which drugs to exclude, and not clinicians, which could block patients from getting needed meds. so, interesting editorial. to me, the issue is who is making the decision about these meds and what power they have. the best scenario to me would be to have a single payor system which would thereby have huge bargaining powe

The LIFE study (Lifestyle Interventions and Independence for Elders) is a multicenter study to assess the effects of physical activity in prevention of major mobility disabilities in older adults (see  physical activity in older dec disability jama2014  in dropbox, or doi:10.1001/jama.2014.5616). background: mobility (ability to walk without assistance) is important for independent functioning and is inversely related to morbidity, disability and mortality. results:     --   1635 sedentary men and women 70-89 yo (mean 79), average BMI of 30, 74% white, 20% african-american, 4% latino, with physical limitations but were able to walk 400 m, were randomized to structured moderate-intensity physical activity (2 center-based visits/week and home-based activity 3-4 times/week with goal of 150 min/week walking, and strength, flexibility, and balance training) or health education program (weekly workshops of health education during the first 26 weeks and then monthly, focusing on preven

study from boston children's hosp looking at kids aged 11-22 coming into ER with acute concussion (see  concussion duration pedi 2014  in dropbox, or doi.org/10.1542/peds.2014-0158#sthash.y90mwnqy.dpuf). assessed duration and course of post-concussive symptoms. not much info in the literature previously about the time-course of symptoms. all pts had blunt head trauma with either alteration of mental status or new symptoms of headache, nausea, vomiting, dizziness, fatigue, drowsiness, blurred vision, memory or concentration difficulty, and no evidence of intracranial hemorrhage. exclusion criteria included glascow coma score <13, skull/long bone fracture, coexisting abdominal/thoracic injury, too much cognitive disability to fill out the questionnaire. Rivermead Post-concussion symptoms questionnaires were given in ER and at 1,2,4,6,8,12 weeks after ER visit.  results:     --235 patients completed at least 1 follow-up questionnaire. mean age 14, 60% male, 22% with loss-

this article was sent to me by gordy schiff. interesting study of perceptions and suggestions of US radiation oncologists and urologists on the effectiveness of active surveillance for patients with prostate cancer (see  prostate cancer active surveillance. medcare2014  or Med Care 2014;52: 579–585 ). baseline is that there are general concerns that prostate cancer is greatly overtreated, and that active surveillance (AS) is appropriate (and in fact recommended) for low-risk prostate cancer (clinically localized disease, PSA in 4-10 range, Gleason 6 or less). results:     --national survey of radiation oncologists and urologists about perceptions of AS, done from nov 2011 to april 2012, with  717 completing survey     --71.9% thought AS effective and 80% thought it was underused     --BUT  for a case patient of a 60yoM  diagnosed with low-risk prostate cancer,  these specialists recommended radical prostatectomy in 44.9%, brachytherapy in 35.4% and AS only in 22.1%. though spe

the "obesity paradox" found in several studies is that normal or underweight people have higher mortality, esp if they have chronic diseases. overall, studies with longer-term databases have found this to be less true, suggesting reverse causality: those with lower weight may disproportionately include people with underlying diseases causing them to lose weight. the current study, a large study with a remarkably good/complete database, adds to this (see  obesity and stroke no paradox jamaneur 2014 , or doi:10.1001/jamaneurol.2014.1017). results:     --71617 patients admitted to Danish hospitals from 2003-2012 with a stroke, with information on BMI in 53,812. looked at deaths likely caused by the index stroke (if the death occurred within the first week or month after the stroke), and recorded in the Danish Stroke Register (coverage felt to be >80% complete).     --mean age 71.2, 47% women, 8% hemorrhagic stroke, mean BMI=25.7, with 10% underweight, 39% normal wt, 35

several medical societies suggest routine hepatocellular carcinoma (HCC) screening in patients with chronic hepatitis b or cirrhosis. a systematic review in annals of intl medicine, commissioned by the VA administration (see  hepatitis hcc screen annals 2014  or doi:10.7326/M14-0558), reviewed the data, finding "very low strength evidence" on the effects of screening on mortality. they found 22 adequate english-literature studies, with results:     --1 large RCT done in China from 1993-95 included 9757 screened patients vs 9443 controls (screening with a-feto protein, AFP, and ultrasound every 6 months), found decreased HCC mortality of  83.2 vs 131.5/100K person-yrs, or rate ratio of 0.63 [95% CI 0.41-0.98]. but significant methodological flaws, including whether there was true randomization (concern that patients in each group did not have same HCC risk, questions about ascertainment of deaths in each group/selective reporting or analysis).     --another Chinese st

Medication adherence issues are one of the most pervasive primary care conundra (?plural for conundrum). i must admit that i always cringe a bit whenever i write for liquid meds for kids, hoping that the pharmacist can appropriately explain how to take the meds and give the appropriate measuring device. (there are other types of educational issues gone awry, evidenced by parents instilling the oral liquid antibiotics directly into the ear, or people taking suppositories by mouth....). so, in this light, there was a study done in new york assessing medication errors and the potential utility of "advanced counseling" in decreasing these errors (see  medical errors liq meds kids acadpeds2014  in dropbox, or  DOI: 10.1016/j.acap.2014.01.003). background: several studies have found that 40% of caregivers make errors in giving kids liquid meds. more if low levels of health literacy, or limited english proficiency. the language used in the instructions can also be confusion (wr

a couple of articles from the ny times. one today, one last year. today's was on the increasing incidence of non-alcoholic fatty liver disease (NAFLD), which is increasingly becoming a significant cause of liver failure and transplantation, ironically as we move forward in eliminating hepatitis C as the major cause til now. the article ( http://well.blogs.nytimes.com/2014/06/13/threat-grows-from-liver-illness-tied-to-obesity/?hp )  notes that:     -- NAFLD has increased dramatically of late (eg now in 10% of children and 20% of adults)     --2-3% of the US population have nonalcoholic steatohepatitis (NASH, the progressive form leading to cirrhosis)     -- nationwide liver transplant  increased from 1% due to NASH in 2001 to 10% in 2009 (and projected to be leading cause for transplants by 2020).       --NAFLD  particularly common in Latinos, partly because they tend to have a genetic variant (PNPLA3), leading the liver to produce and store more triglycerides.  e

i  will editorialize on a recent editorial in  JAMA , which argues that adiposity may be the cause and not the consequence of overeating (see  obesity as cause for overeating  jama2014  in  dropbox , or  JAMA . 2014; 311(21): 2167). this editorial was written by  david   ludwig  at  boston   childrens  hosp, founder of the OWL clinic there (optimum weight for life), and longstanding champion of low- glycemic  index diets (he wrote the seminal article on it -- at least from what  i've  seen -- in 2002, which reviews data and provides a theoretical framework --see  glycemic  index  ludwig   jama   2002.pdf  in  dropbox , or  JAMA . 2002; 287(18): 2414).  i suspect that the effectiveness data on low GI diets for weight loss, which is really no different from other diets, has more to do with the ability of patients to adhere to the diet long-term, as opposed to the specific diet itself. hard to adhere  longterm  when people are bombarded with calorie-dense, high  carb  foods (adverti

recent systematic review/meta-analysis of interventions to prevent readmissions for pts with heart failure (see  chf  interventions to decrease readmissions  annals2014  in  dropbox , or Ann Intern Med. 2014;160:774-784). review was funded by Agency for Healthcare Research and Quality ( AHRQ ) background:     --heart failure ( chf ) is leading cause of hospitalizations (and health care utilization) in US     --25% of pts admitted with  chf  are readmitted within 30 days (35% of them readmitted with diagnosis of  chf . rest with renal  dz , pneumonia, etc) results:     --47 trials of diverse interventions to prevent readmission. pts with moderate to severe  chf . mean age 70.     --at 30 days, high intensity home-visiting program (nurse or pharmacist usually) reduced all-cause readmission and combo of that plus death, though low quality of evidence     --over 3-6 months, home-visiting program and multidisciplinary heart failure clinics reduced all-c

lots of interesting articles, several sent out, over the past year on the microbiome and on allergen exposures and subsequent allergies. recent one of the Urban Environment and Childhood Asthma study (URECA), done in several urban areas (baltimore, boston, new york, st louis), a study of 560 kids at high risk of developing asthma and followed since birth for 3 years with environmental assessments including allergen exposure.  also, a second study looked at  a nested case-controlled study of 104 kids assessing the bacterial content of their house dust exposure -- see  asthma early exposure allergens jallergclinimmun 2014  in dropbox, or doi.org/10.1016/j.jaci.2014.04.018. results:     --cumulative allergen exposure over first 3 years of life associated with allergic sensitization and related to recurrent wheezing     -- BUT , first-year exposure to cockroach, mouse and cat allergens was  negatively  associated with recurrent wheezing (ORs of 0.60, 0.65, and 0.75 respectively an

there have been a couple of warning-type articles in the past couple of years about adverse effects of azithromycin, especially cardiac deaths. as i suggested previously (see below), azithromycin is a really important antibiotic, but should be targeted only for significant bacterial infections -- and it seems mostly to be used unnecessarily (see prior blog below). a recent large cohort study did find some increased likelihood of MI but, most significantly, a lower 90-day mortality (see  azithromycin decreases mortality in elderly jama 2014  in dropbox, or doi:10.1001/jama.2014.4304).  those on azithro were on combo therapy. others received guideline-concordant therapy. results:     --retrospective study from 2002-2012 of 73,690 patients older than 65 (mean age 77.8) from 118 VA hospitals who were hospitalized for community-acquired pneumonia, comparing 30- and 90-day outcomes, and matching 31863 on azithromycin vs same number not. high levels of comorbidities: 40% smokers, 52

recent comprehensive systematic review and meta-analysis of studies looking at pharmacotherapy for alcohol use disorders (which are associated with 3x increase in early mortality, only 30% of patients receive treatment, and <10% are prescribed meds to decrease alcohol consumption) – see    alcohol meds jama 2014  in dropbox, or doi.org/10.1001/jama.2014.3628.  Reviewed 123 studies, almost all RCTs, with 22.8K participants. Mean age in 40’s. studies from 12-52 weeks long. Mostly enrolled patients after detox or at least 3 days off alcohol. Results (significant findings only):                 --acamprosate tid ( a glutamine antagonist and γ-aminobutyric acid agonist) : NNT (# needed to treat) to prevent return to any drinking=12;                 --naltrexone 50mg/d: NNT to prevent any drinking =20; NNT to prevent return to heavy drinking=12. --In trials comparing these 2 drugs – no signif difference --injectable naltrexone: no effect on return to drinking or heavy drinking,