geoffrey modest medical blogs

a series of 3 articles in Lancet on where we're at and future possibilities about lipids: one on LDL, one HDL, and other Triglycerides (TG). brief review of points. 1. LDL (see  lipids LDL controversies lancet 2014  in dropbox, or Lancet 2014; 384: 607–17) --reinforces that calculated LDL (by Friedewald equation) is usually adequate to evaluate LDL (though underestimates true LDL if high TGs, esp if LDL is very low either naturally or by using statins), or when HDL is very high. No need to get direct LDL, unless unable to calculate (usually because of very high TG). --promotes the use of non-fasting lipid measurement. also, there are somewhat stronger data that the non-HDL lipid fraction (total chol minus HDL) is a better predictor of events than LDL, both in those on statins and not on meds (see below as well). --there are data from several studies that the relative risk reduction of statin use is higher in those with lower absolute risk, supporting the concept that i

so, here's another microbiome article -- as mentioned in previous blogs, i do find this microbiome stuff fascinating and have sent out articles on gut and lung microbiomes in the past, in part because it gives us a mechanistic window into the rather profound relationship between the environment and disease (eg, the TMAO study showing that for red meat eaters, as opposed to vegan eaters, there is a change in the gut microbiota so that if given a red meat meal, more cardiotoxic TMAO is generated --see  cad red meat TMAO nature medicine 2013   in dropbox , or doi:10.1038/nm.3145), and i think this microbiome focus provides even greater imperative to avoid overuse of antibiotics (which profoundly change the microbiota) and possibly increase use of probiotics. recent review article in Lancet has current insights into lung microbiome and disease (see  lung microbiome and disease lancet 2014  in dropbox, or Lancet 2014; 384: 691–702​). brief summary of key points: --microbes normally

Article in JAMA this week on benefit of patients' blood pressure monitoring and self-management (see  htn self-monitoring titrating dec bp jama 2014​  in dropbox, or doi:10.1001/jama.2014.10057). in this UK study 552 high-risk patients (at least 35 yo with history of stroke or TIA; coronary artery disease with either CABG, MI or poorly controlled angina; diabetes; or chronic kidney disease stage 3 with GFR 30-59, and a baseline BP>130/80), were randomized (unblinded) to the intervention (blood pressure self-monitoring with  individualized self-titration algorithm) vs control (usual care),  with target BP of 125/75). patients were excluded if BP>180/100, or on more than 3 BP meds. main outcome was difference in systolic blood pressure after 12 months. results: --mean baseline BP was 143/80. mean age 70, 60% men, 97% white, BMI 31, 79% professional or skilled workers,  --after 12 months: the intervention group achieved BP 128/74, control group 139/77, with a significan

Recent Lancet meta-analysis  looking at the benefits of blood pressure lowering and relating that to overall cardiovascular risk  ( see  htn blood pressure reduction cardiovasc risk lancet 2014  in dropbox, or Lancet 2014; 384: 591–98​ ). Findings: --11 trials with 67,475 individuals, with  52K having data for overall cardiovasc risk assessment. 4167 (8%) had cardiovasc event over mean of 4 years. the data incorporated into their risk model included age, sex, BMI, syst and diast bp, antihypertensive meds, smoking, diabetes, hx of cardiovasc disease. did not have enough data about lipids. baseline 45% female, ave age 65, 15% smokers, 39% diabetic, BMI 27.8, BP 158/92. --likelihood of cardiovasc event tracked with overall 5-yr cardiovasc risk. relative risk reduction (RRR) were and absolute risk reduction (ARR) for 1000 pts treated for hypertension for 5 years would be:                 --cardiovasc risk 6%: RRR 18% and ARR of 14 cardiovasc events/1000 pts treated              

a low-key, low-cost post-hospital smoking cessation program had pretty impressive results (see  smoking cessation hosp pts jama 2104  in dropbox, or doi:10.1001/jama.2014.9237 ​). in this randomized controlled trial, 397 hospitalized daily smokers (at least 1 cigarette/d) who wanted to quit smoking were randomized to either "sustained care", which consisted of automated interactive voice response telephone calls for the first 3 months, promoting smoking cessation, medication management, problem-solving approaches, and the option for additional counseling, along with their choice of free smoking cessation medications for up to 90 days, vs. "standard care", which involved recommendations for post-discharge pharmacotherapy and advice through a free telephone quit line.  primary outcome was biochemically-confirmed (saliva cotinine analysis) past 7-day abstinence at 6-month followup.  results: --mean age of participants was 53, 48% male, 81% non-Hispanic whites.

in response to the public health crisis related to prescription opioid diversion/ street availability/ deaths, there have been a couple of very-long-past-due changes by the DEA: 1.  Hydrocodone  (found in Vicodin, Lortab) is now being considered a Schedule II drug (as with all the other strong opioids), to take effect in 45 days.  it was really egregious that this had not been before, since it has the same morphine-equivalent strength as morphine!!!  so, will soon need to be handled as the others (written script for one month only, no refills permitted), and (hopefully) will have tighter govt regulation.   see  https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-19922.pdf ​ if you would like the gory details. 2.  Tramadol , a lower potency opioid (10 mg of tramadol is considered 1 morphine equivalent), is  now Schedule IV (as of 8/18/14), which means that it is in the same group as benzos (ie, needs written/signed  prescription with DEA number, and can get up to 6

2 international studies were published in new  engl  journal of medicine last week, from the PURE investigators (Prospective Urban Rural Epidemiology). 1.  102K  people from 18 countries (low, middle and high income countries, on 5 continents) estimating 24-h urinary sodium and potassium excretion (which reflects intake) from a single fasting urine sample and blood pressure (see   htn  sodium potassium excretion  nejm  2014  in  dropbox , or  DOI : 10.1056/ NEJMoa1311989) ​. findings: --regression analysis showed 2.11 mmHg increase in systolic and 0.78 in diastolic for each 1-g increment in estimated sodium excretion. (average sodium excretion 4.93 g/d) --the association was nonlinear (and similar results were found for diastolic readings):          --in those excreting > 5gm /d, there was an increment of 2.58 mmHg systolic         --in those excreting 3-5  gm /d, there was an increment of 1.74 mmHg systolic         ​-- in those excreting <3  gm /d, there was an

i  found this recent study suggesting a relationship between vitamin d deficiency and cognitive impairment ( see  vit d and dementia neuro 2014  in dropbox, or doi.org/10.1212/WNL.0000000000000755#sthash.O7EPM0di.dpuf ). as noted in prior blogs and summarized in older reviews (eg, see  vit d review nejm 2007  in dropbox, or N Engl J Med 2007;357:266-81), there are vitamin D receptors throughout the body, with likely importance in immune function (and inverse relationship between vitamin d levels and several immunologic diseases, and an intriguing study finding that supplementing vitamin d led to improved outcomes in treatment of tuberculosis), cancer development, diabetes, all-cause mortality, as well as bone and muscle function -- see the dropbox for a myriad of articles. on scanning the contents of the journal Neurology over the past 2 years, there have also been a slew of articles associating vitamin D deficiency with increased risk of multiple sclerosis exacerbations, gait disturb

so, you might ask, why am i reviewing for primary care providers such a pretty obscure study in a pretty obscure journal (Gastrointestinal Endoscopy)? mostly because i think that proton pump inhibitors (PPIs) are over-prescribed (as well as available over-the-counter) and may well be dangerous, esp with long-term administration. studies have shown that in the treatment of GERD, for example, there have been 2 strategies: the step-up (ie, start with lower potency calcium, then to H2 blockers, then to PPIs as needed) vs step-down (start strong with PPIs, then titrate down). both seem theoretically reasonable, except that in practice the step-down strategy is rarely implemented (ie, patient is doing well on PPI, so just refill the prescription -- why change something that works and makes the patient feel better??). there are several issues with long-term PPI usage, largely related to hypochlorhydria and/or the extreme hypergastrinemia associated. although the data in many cases is not com

potentially useful study done in Denmark looking at the prevalence of c. difficile infections in community patients seen for unformed stools (see  cdiff in community clin microbio 2014 ​ in dropbox, or  doi.org/10.1111/1469-0691.12758#sthash.lfaoG3fB.dpuf). details: --12174 "unformed stool" samples sent to lab for evaluation for any enteric pathogen by general practitioners were then automatically tested for c. diff --194 samples (1.5%) were positive for c diff, comparable to incidence of salmonella. they did  nested case-control study, with 152 c diff patients compared with 304 age and sex-matched controls and  using weighted multi-variable logistic regression --compared to others with diarrhea, those with c diff had more severe complaints, underlying diseases, antibiotic use, prior hospitalization (none of this particularly surprising) --but in Denmark, MDs requested c diff testing in only 7% of samples (which detected only 40% of the cases) --and, if following