geoffrey modest medical blogs

The American Academy of Pediatrics updated their 2006 guidelines on diagnosis and treatment of bronchiolitis (see  bronchiolitis practice guideline Peds 2014 or go to  http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742.full.pdf+html). in brief: --for diagnosis: it's all in the history and physical for both diagnosis and assessing disease severity -- assess risk factors for severity (<12 weeks old, history of prematurity, underlying cardiopulmonary disease or immunodeficiency). not routinely need xray or labs if clear diagnosis --for treatment: NOT USE  albuterol (new recommendation), epinephrine, nebulized hypertonic saline except if hospitalized (data suggest only useful in kids on this for 3 days for severe cases, and at least 24 hours in mild to moderate disease), steroids, supplemental oxygen if O2 sat>90%, chest PT, antibiotics (unless concomitant bacterial infection or strong suspicion). use nasogastric or IV fluids if infant can

As we are well aware here , methicillin-resistant staph (MRSA) infections are very common in the community. We have had very good success overall with trimethoprim/sulfa (TMP/SMX), though for deep-seated infections, I have prescribed linezolid (which is very expense, >$100/pill, and requires a prior approval). So, being strongly prior-approval averse, I was impressed with a Swedish trial showing non-inferiority between TMP/SMX plus rifampin and linezolid (see MRSA tmpsmx rifamp as good J Antimicrob Chemo 2014 in dropbox, or doi:10.1093/jac/dku352). Study publically-funded. Details: --150 patients (ave age 69, 68% male, 93% hospitalized for infection but of those 31% were elective admission), most with significant comorbidities (63% cardiovasc,17% pulm, 20% renal, 25% cancer…) given either TMP/SMX DS tid plus rifampin 600 daily vs linezolid 600 bid --all had had sensitivity testing and found to be susceptible to all of the meds prior to randomization --most had deep-seated

so, another microbiome blog (i can't help myself). in a 5-year observational study of 720 patients with heart failure followed at the Cleveland Clinic, elevated levels of TMAO (trimethylamine-N-oxide) were associated with long-term mortality, independent of traditional risk factors and BNP or renal function (see  chf and microbiome TMAO JACC 2014 in dropbox , or doi.org/10.1016/j.jacc.2014.02.61).  per prior conceptions, the role of the gut in heart failure was basically that splanchnic circulatory congestion led to changes in gut permeability and in intestinal barrier integrity leading to entry into the circulation of lipopolysaccharides from gram negative bacteria, activating cytokines and creating systemic inflammation. the current study basically found that the plasma TMAO levels were increased in those with CHF.  TMAO is derived from foods containing carnitine (eg red meats) or lecithin (eg from eggs). (see the blog from 4/8/13 at the end, which found that consumption of re

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 treatments could change the risk/benefit analysis of screening in the future).  of note, the arena smoking-related morbidity is changing: tobacco companies have seen shrinking local markets (showing that sometimes after decades of obvious connection with lung

chocolate (actually dietary epicatechin) does increase the dentate gyrus function on functional MRI and improve cognitive testing in only 3 months (see chocolate and cognition. nature neuro 2014 in dropbox, or  doi:10.1038/nn.3850). a couple of other observations from the paper. --data in mice show a synergy between flavanols and aerobic exercise in enhancing dendritic spine density in the dentate gyrus --this increase in both function (mice have improved cognitive performance with flavanols) and structure occur in association with an increase in capillary density in the dentate. --the researchers developed a cognitive test, which mostly was looking at a large series of complex images, then 1 second after each image they asked which of 2 similar objects was present in the complex image, timing the subjects’ responses. Each time the test was performed, different images were used. --they tested this cognitive eval  in undergraduates and in healthy subjects aged 21-69, findin

BMJ had a recent systemic review and meta-analysis of urinary screening for HPV (see  hpv urine screen bmj 2014 in dropbox, or  doi: 10.1136/bmj.g5264), including 14 studies with 1443 women, comparing urine HPV DNA screen with cervical DNA screen. findings: --urine detection of  HPV  had a pooled sensitivity of 87% (CI: 78-92%), and specificity of 94% (CI: 82-98%) --urine detection of high risk HPV (15 serotypes assessed) had  a pooled sensitivity of 77% (CI: 68-84%), and specificity of 88% (CI: 58-97%) --urine detection of HPV  16/18 (the worst of the high-risk)  had a pooled sensitivity of 73% (CI: 56-86%), and specificity of 98% (CI: 91-100%) --translation of above: the high specificity suggests that positive test results are 15 times more likely to occur in HPV positive women; the less-high sensitivit y suggests that a negative test results would happen only 7 times more frequently in non-infected women. for those with HPV ​ 16/18, positive test results are 37 times mo

JAMA just published a good up-to-date review article on the diagnosis and treatment of uncomplicated urinary tract infections, defined as acute onset of dysuria, frequency or urgency in a healthy, nonpregnant woman without known functional or anatomical abnormalities of the urinary tract (see  urinary tract infection review jama 2014​ in dropbox, or doi:10.1001/jama.2014.12842), incorporating all articles published until july 2014 (and not including treatment articles before 2000 since the bacterial resistance patterns have changed so much). they assessed 27 RCTs and clinical trials with 6463 patients, 6 systematic reviews and 11 observational studies with >250K patients.  their conclusions: --diagnosis: women with at least 2 symptoms of UTI (dysuria, urgency or frequency) and the absence of vaginal discharge have >90% probability of acute cystitis. adding a urine dipstick for leukocyte esterase does not really change the probability, and studies show no benefit of urine cult

no shocker here, but it turns out that non-vitamin D fortified non-cow's milk (eg goat's milk or plant-based milk such as soy, rice, almonds...) leads to lower 25-OH vit D levels in the blood. in this canadian study, they looked at serum 25-OH in kids who were drinking non-cow's milk (which is only voluntarily fortified with vit D and, if so, with no regulation of content) vs those on fortified cow's milk,  by law required to have 40 IU vit D/100 ml (see  vit d and kids on non-cows milk cmaj 2014 ​ in dropbox, or DOI:10.1503/cmaj.140555​). note that this was an observational study, not RCT -- so there might be other confounders (eg, those on non-cow's milk are on it for specific reasons which could also affect their vitamin D levels, or have other dietary changes in addition to non-cow's milk). results: --2268 children aged 1-6 yo, coming in for routine well-child visits, had dietary history and blood tests. of these, 1950 drank only cow's milk, 146 on

A new long-term analysis of the Bogalusa Heart Study (in Bogalusa, LA) in kids has confirmed a longitudinal relationship between obesity and hypertension in the development of left ventricular remodeling/hypertrophy, with obesity being the most significant driver (see  obesity kids and LV remodeling bogalusa JACC 2014 in dropbox, or doi.org/10.1016/j.jacc.2014.05.072)  . there are a slew of studies finding that obesity and hypertension are associated with LVH (left ventricular hypertrophy). prior pediatric epidemiologic studies from several different countries have pretty consistently found that there is an association between cardiovasc risk factors in kids and increased left ventricular mass, and that early risk factors predict adult LVH as well as LV geometry. the current analysis looked at the long-term burden and trends of cardiovasc risk factors in kids and the development of LVH and LV geometry. The Bogalusa Heart Study is a biracial community-based study (65% white, 35% blac

Two research letters appeared in JAMA specialty journals recently, reflecting antibiotic overprescribing. 1. the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey has lots of data on ambulatory care visits and includes patient demographics, ICD-9 diagnostic codes, and medications prescribed. this first report (see  antibiotic overprescribing jama pedi 2014 in dropbox, or doi:10.1001/jamapediatrics.2014.1582)  analyzes data from 1997-2011 for patients 3-17yo seen for sorethroat, and excluding visits with other infections present (eg cellulitis, which would require antibiotics), for a total of approx 12 million visits annually, finding: --antibiotics prescribed for 60%, with 61% given narrow-spectrum antibiotics (penicillin, amoxacillin), and 39% given broad-spectrum (mostly macrolides, followed by second/third generation cephalosporins, then amox/clavulanate and first generation cephalosporins) --over the 14 years of the study, sc

so, i don't mean to overdo this HDL thing, but there was a new study finding that a synthetic oral HDL mimic significantly reduced atherosclerotic plaques in mice (see lipids HDLnanoparticle mice JLR 2014 in dropbox , or DOI 10.1194/ jlr.M049262 ). details (in very brief): --they created HDL-like nanoparticles (based on multiple apo-A-1 mimetic peptides on a scaffold) and administered them to LDL receptor-null mice (a commonly used animal model for atherosclerosis, with a human-like lipoprotein profile) for 10 weeks orally.  --the oral med was undetectable in the blood, but caused significant reductions in VLDL and LDL but increases in HDL (perhaps by intestinal effects), and reduced the development of whole aorta atherosclerotic lesions by 55% and aortic sinus lesions by 71% . They note that the plasma changes in lipids was these apo A-1 mimetic peptides were much more than other apo A-1 mimetics, which typically do not change cholesterol levels but do decrease atheroscl

An updated guideline came out of the Infectious Diseases Society of America on the management of chronic kidney disease in patients with HIV (see hiv chr kidney dz infect dis society 2014 in dropbox, or  doi: 10.1093/cid/ciu730 ​). they note that chronic kidney disease is common in people with HIV, can be multifactorial (including direct HIV renal involvement and adverse medication effects), and is itself associated with increased morbidity and mortality. people with HIV with decreased GFR and albuminuria have an even higher risk of cardiovascular events (6-fold) than the increased risk in the general population (of note, the decreased GFR and albuminuria are independently associated with cardiovascular events, worse if both are present).  the guideline committee stresses that these are guidelines and not intended to supplant clinical judgment in the management of individual patients. recommendations: --check eGFR when antiretroviral therapy is initiated or changed, and a

i don't want to shock you, but it seems that of the 300 top paid doctors by big pharma and medical device companies, 90% are men. no doubt for many reasons, including their predominance at the head of many of the highly paid specialty societies (as i plow through many of the guidelines generated by different specialty organizations, it is pretty remarkable how few women are on these committees). for the link to the article:  http://www.nytimes.com/2014/10/09/upshot/men-dominate-list-of-doctors-receiving-largest-payments-from-drug-companies.html?ref=policy&_r=0&abt=0002&abg=0 ​ 

see below, from karen henley. the article basically discusses how the troves of information in the electronic medical record (much of which is useless, redundant, and a waste of time to read) actually often leads us to spend less time with the patient, clutters our minds with preconceptions of what is going on, and may make it more difficult for us to get a good, primary, unfiltered history from the patient. Geoff, did you see this article? Feel free to disseminate. Take care, Karen http://well.blogs.nytimes.com/2014/10/13/with-electronic-medical-records-doctors-read-when-they-should-talk/?_php=true&_type=blogs&src=me&_r=0

there have been a couple of recent articles on testosterone, though please note the older blog from 4/3/14, appended below.  1. article in j clin endocrinology and metabolism on testosterone therapy for men with type 2 diabetes (T2D) and low testosterone levels (see  dm testosterone not help sex jcem 2014​ in dropbox, or doi: 10.1210/jc.2014-1872). 88 men aged 35-70 (ave age 62) with A1c <8.5%, total testosterone (TT) < 346 ng/dl (they specifically were looking for men with low normal testosterone levels, and excluded those with TT < 144), with mild to moderate"aging male symptoms" and erectile dysfunction, randomized to 40 weeks of IM testosterone undecanoate 1000 mg or placebo, assessing their AMS (aging male symptoms score, a validated 17-item scale to assess 3 domains: somatovegetative, psychological, and sexual), as well as sexual desire and erectile function. this analysis was a secondary one, with the primary study finding in these men that testosteron