geoffrey modest medical blogs

JAMA just had an article on a successful, long-term public health initiative for the prevention of cardiovascular disease in a rural low-income area in Maine (see  cad risk prevention community prog JAMA 2015  in dropbox, or  JAMA . 2015;313(2):147-155 ). this program involved a 40-year observational study in Franklin County, Maine, looked at the pre-intervention period of 1960-70, then the 40 year period thereafter in which sequential risk factor reduction programs were initiated, and compared this all to the statistics for the whole state. background:     --Franklin County is a rural, poor small county in northwestern Maine, with 22,444 residents in 1970 growing to 30,768 by 2010; predominantly white (99.9% In 1970 to 97.2% in 2010); increasing in elderly (those >65 yo, from 10.8% to 23.0%); decreasing younger population (those <18yo from 35.3% to 26.9%); increasing poverty (from 9.0% to 16.8%), though increasing % completing high school (57.2% to 87.9%). also more prima

Interim guidelines were just released on primary HPV testing in women for cervical cancer (ie, without doing a pap smear at the same time), from the Society of Gynecologic Oncology and the American Society for Colposcopy and Cervical Pathology, and including experts from the American Cancer Society and American College of Obstetrics and Gynecology (see  hpv based screening gyn oncol  2015  in dropbox, or  doi.org/10.1016/j.ygyno.2014.12.022 ​).  their conclusions were largely  based on a prospective company-sponsored cohort study of 47,208 US women, finding that for primary HPV testing as compared to cytology alone (respectively):     ​--the sensitivity for >CIN2 was 58.26% vs 42.63%     --the risk of >CIN2 (positive predictive value) was 12.25% vs 6.47%     --the risk of >CIN2 in women who were not referred to colposcopy was 0.42% vs 0.59%     --the false positive rate for >CIN2 was 4.09% vs 6.04%     --the improvement in the sensitivity and negative predictiv

The Annals of Intl Medicine had a recent systematic review (137 studies with 33,243 participants) and network meta-analysis of different therapies for knee osteoarthritis, including acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) steroids, IA hyaluronic acid, oral placebo and IA placebo (see  knee arthritis therapies AIM 2015  in dropbox, or Ann Intern Med. 2015;162:46-54​). a network meta-analysis is a mathematical construct to assess the data from multiple individual head-to-head comparisons and integrate it all into a single comparative analysis results: --median age overall was 62, 67% women --for pain (129 trials, 32,129 participants), all interventions were better than placebo. size effects ranged from 0.63 for most efficacious treatment (IA hyaluronic acid) to 0.61 for IA steroids, 0.52 for diclofenac, 0.44 for ibuprofen, 0.38 for naproxen, 0.33 for celexoxib, 0.29 for IA placebo, and 0.18 for acetaminophen. --for function (76 trials, 2

one pretty common primary care issue is the safety of stopping oral anticoagulant therapy (OAC) in patients who have a first, unprovoked venous thromboembolism (VTE). the risk of recurrent VTEs is variable in the studies (5-27% in first year, then 2-4%/yr).  A Canadian study was just released looking at 410 adults with first unprovoked VTE who completed 3-7 months of OAC (see  dvt stop anticoag AIM 2015  in dropbox, or Ann Intern Med. 2015;162:27-34​).  OAC was discontinued if the D-dimer were negative on therapy, and not restarted if D-dimer were still negative after 1 month. they assessed recurrent VTE over 2.2 years. baseline: mean age 51, BMI 37, 45% with DVT and 55% with PE, and not much difference in baseline characteristics between men and women. women were divided into 2 groups: those with VTE who were on estrogen therapy (who then stopped the estrogens), and those who were not on estrogen therapy. results:     --78% had 2 negative D-dimers and did not restart OAC. o

a rather disturbing article was just published on trends in the ambulatory management of headache  (see  headache treatment trend JGIM 2015  in dropbox, or DOI: 10.1007/s11606-014-3107-3). this analysis looked at a nationally representative sample from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (not including ER visits) and excluded those patients with red flags (neurologic deficit, cancer, trauma), with the following findings: --9362 visits for headache assessed, which represents 144 million visits over the study period of 1999-2011 --mean age 47, 75% female, 75% white --use of CT/MRI rose from 6.7% of visits in 1999-2000 to 13.9% in 2009-10. report did not differentiate CT vs  MRI. --referrals to other physicians rose from 6.9% to 13.2% --but, clinician counseling declined from 23.5% to 18.5% (counseling includes: lifestyle modification, diet/exercise counseling, stress management, discussing potential psychosocial in

JAMA just published a systematic review of the literature on the use of metformin in patients with chronic kidney disease  (see  dm metformin ckd jama 2014  in dropbox, or  JAMA. 2014;312(24):2668-2675 ​). the major concern is that metformin is renally-cleared, and that its close cousin, phenformin, was used extensively in the US, caused large numbers of cases of fatal lactic acidosis and was pulled off the market in 1977. major points from the systematic review: --65 studies identified, mostly case series and observational post-marketing surveillance but also some pharmacokinetic/metabolic ones -- though there is reduced metformin clearance with renal insufficiency , both  metformin and lactic acid levels are in safe ranges in patients with eGFR of 30-60 mL/min/1.73m 2 --the incidence of lactic acidosis in metformin users is 3-10/100K person-years, "generally indistinguishable from the background rate". for example,  an analysis of 347 studies of diabetics found no

i have sent out several different concussion guidelines over the past few years -- most recently ones by the  american  academy of neurology in 2013 (see  http://www.neurology.org/content/early/2013/03/15/WNL.0b013e31828d57dd  ), and the Ontario  Neurotrauma  Foundation in 2014 (see  http://onf.org/system/attachments/266/original/GUIDELINES_for_Diagnosing_and_Managing_Pediatric_Concussion_Recommendations_for_HCPs__v1.1.pdf ​ ) these guidelines are pretty complete, but as i have noted in prior blogs, they tend to be conservative (mostly because there are not much great data available regarding many of the recommendations, so they err to being appropriately pretty aggressively conservative, with many of their specific recommendations based on animal studies in conjunction with the known increased susceptibility of adolescents to concussion  sequelae ). in this setting, a Wisconsin study compared patients aged 11-22 with concussions to see if strict rest afterwards really mattered (s

a recent article from the Netherlands looking at hepatitis C (HCV) infection and reinfection in HIV positive MSM (men who have sex with men) sheds some light on the murky subject of  HCV  virology  (See   hep  c reinfection  clin   inf   dz  2014  in  dropbox , or Clinical Infectious Diseases 2014;59(12):1678 – 85).  it has been known that anti-HCV antibody titers can decline in both acute and chronic  HCV  infection and can even lead to seroreversion (ie, negative blood test for anti-HCV antibody). in this study, 63 people, who were followed a median of 4 years with  HCV  testing at least annually, seroconverted from negative anti-HCV Ab to positive. these men denied injection drug use and "phylogenetic analyses of circulating HCV strains have revealed the presence of multiple MSM-specific clusters". the researchers differentiated HCV reinfection (either infection with a different genotype than the initial infection, or at least looking for changes in certain genetic sequen

JAMA had an excellent review (i think) of traveler's diarrhea (see  travelers diarrhea jama 2015  in dropbox, or JAMA. 2015;313(1):71-80​). some of their major points for those traveling to high-risk countries: --eating food from street vendors certainly increases the risk, though one can get it in a 5-star hotels (esp if food served buffet-style and food exposed to warm environmental conditions) --average duration of the diarrhea is 4-5 days, though mean duration of incapacitation is <1 day. but passage of more than 10 stools/d is pretty uncommon (reported in 3% of cases) --long-term complications can occur: postinfectious irritable bowel syndrome (PI-IBS) can occur in 3-17%, some without prior traveler's diarrhea, though PI-IBS tends to occur in those with more serious cases and esp in those infected with heat-labile toxin-producing enterotoxigenic e. coli --there is a great table (their Table 2) of the regional differences in the etiology of traveler's diar

A recent analysis of the Atherosclerosis Risk in Communities study (ARIC, a prospective community-based cohort study from 4 communities across the US) assessed 13351 black and white adults aged 48-67 in 1990-92, and assessed changes in cognitive function over the next 20 years. baseline: --population: average age 57, 56% female, 24% black, 13.3% with diabetes --cognitive assessment: 3 tests -- delayed word recall test (DWRT, a test of verbal learning and recent memory); digit symbol substitution test (DSST, a test of executive function and processing speed), a component of the Weschler adult intelligence scale-revised; and the word fluency test (WFT, a test of executive function and language), all checked at baseline and at least 2 more times. --they assessed stored blood for A1c values and controlled for age, race, education level, smoking, alcohol, BMI, hypertension, history of CAD, history of stroke, and apolipoprotein e4 genotype results: --20-year decline in cogni

the American Diabetes Association just updated their clinical care recommendations, as they do annually. (see  dm diabetes care summary 201 5  in dropbox, or go to  http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/Documents/January%20Supplement%20Combined_Final.pdf ​ ). I will highlight the significant changes over last year, though i did repeat a few items of importance which did not change. --they lowered the BMI cutpoint for overweight in Asian Americans from 25 to 23 kg/m 2 , reflecting the observation that there is an increased incidence of diabetes at lower BMIs in Asians. They continue to recommend checking for diabetes in all overweight/obese patients (with the above change for Asian Americans) who have one additional risk factor at any age, and to begin at age 45 otherwise [my comment: there are many, many studies over the years showing that central or visceral obesity is a much stronger cardiovascular risk factor than BMI.  BMI assesses overall weight, which