geoffrey modest medical blogs

the treatment of depression in the elderly can be very difficult. the usual meds (SSRIs) tend to be less effective in the elderly, with some studies not finding much difference from placebo. and psychotherapy, which does help some, is often also less effective, given that many elderly do not have much insight into their condition and many also find it difficult to change. there have been studies in the past showing significant efficacy of stimulants, especially in those with severe depression (eg, a study at Mass General Hosp of 129 geriatric inpatients with severe major depression found 66% with significant improvement within 1-2 days, and only 8% with adverse reactions and none with reduction in appetite. average doses of dextroamphetamin was 8.2 mg and methylphenidate 8.2 mg. see  J Geriatr Psychiatry Neurol. 1990;3(3):146 . other old studies have found an overall response rate of 81%.  i am unaware of newer studies). in this context, a 16 week RCT was done of 143 geriatric out

an independent study (sponsored by Agency for Healthcare Research and Quality, for an NIH workshop) did a very thorough systematic review of the effectiveness and risks of long-term opioids for chronic pain (see  opioids and long term efficacy  chr  pain annals 2015  in  dropbox , or Ann Intern Med. 2015;162:276-286​), where chronic pain is defined as lasting longer than 3 months  or beyond the normal time for tissue healing. they  acknowledge  that  chronic  pain is common and associated with decreased quality of life and with disability. and they note that there has been a dramatic increase in opioid med prescriptions, with attendant increases in overdose, abuse, addiction and diversion.  their findings: --Long-term effectiveness of opioids: "No study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy evaluated long-term (>1 year) outcomes related to pain, function, or quality of life"  (and that is all they say about effectiveness) --Harms:

will pass along the infectious disease society "choosing-wisely" recommendations for decreasing antibiotic use. although none of these are new or surprising, data suggest that antibiotics are still being prescribed for these conditions unwisely....  (see  http://www.choosingwisely.org/doctor-patient-lists/infectious-diseases-society-of-america/  ) 1. don't treat asymptomatic bacteruria with antibiotics. (except pregnant patients, those undergoing invasive urological surgery including prostate surgery, or those within 1 year of kidney or kidney pancreas transplant) 2. avoid antibiotics for upper respiratory infections. most are viral. but one should treat group A strep and pertussis 3. don't use antibiotics for stasis dermatitis of lower extremities. use leg elevation and compression. [in my experience, this can be a difficult call: stasis dermatitis can really look like cellulitis with bright red, well-demarcated erythema, though with less induration than cel

New Engl J of Med just published the LEAP (Learning about Peanut Allergy) study, which looked at early feeding of peanuts to infants at   high  risk  of having peanut allergy, showing a dramatic decrease in subsequent allergy  (see  p eanut allergy early food intoduction NEJM 2015  in dropbox, or  DOI: 10.1056/NEJMoa1414850 ). see prior blog for other recent data on early food consumption, the effect on the gut microbiome, and subsequent development of allergy, including suggestions from a couple of years ago that introduction of peanuts made sense ( http://gmodestmedblogs.blogspot.com/2019/04/food-diversity-in-young-kids-and.html   ).  the background, in brief, is that the prevalence of peanut allergy in kids has exploded (doubling in past 10 years, to reach prevalence of 3%), this is the leading cause of anaphylaxis/death from food allergies, peanut allergy in kids has huge psychosocial ramifications for the kids and parents, and there are remarkable differences in different countri

a recent article in the Annals of Internal Medicine looked at the causes of pharyngitis at the University of Alabama at Birmingham student health center (see  pharyngitis fusobacterium annals 2015  in dropbox, or Ann Intern Med. 2015;162:241-247​). details: --312 students aged 15-30 with acute pharyngitis were compared to 180 asymptomatic students (mean age 23, about 60% women, 74% white) --PCR was done on the throat swabs to detect Fusobacterium necrophorum, Mycoplasma pneumoniae, and group A and  group C/G b-hemolytic streptococci. and the Centor score was calculated  (Centor, by the way, is the lead author of this study). the Centor score is 1 point for each of fever, lack of cough, tender anterior cervical nodes, and tonsillar exudates, with higher scores more likely to reflect group A strep infection. --results:     --F necrophorum in 20.5% of those with pharyngitis and 9.4% of the asymptomatic     --group A strep in 10.3 vs 1.1%     --group C/G strep in 9.0 vs 3.

​A retrospective analysis from the CDC  was done of hospitalizations for hepatitis A, using the National Inpatient Sample -- the largest population-based hospital inpatient database in the US, with annual data from about 1000 non-federal hospitals  (see  hepatitis A hospitalizations  hepatol  2015  in  dropbox , or  HEPATOLOGY  2015;61:481-485). they looked at data from 2002 to 2011. results: --hospitalizations for hep A decreased from 0.72/100K to 0.29/100K (which has been attributed to universal vaccination of kids 12-23 months old) --BUT there was          --an increase in the mean age of the hospitalized patient (37.6 to 45.5 years), with increases in those 40-64 and >64 yo groups but decreases in those <18 and 18-39 yo         --an increase in discharge comorbid medical conditions and other liver diseases         --an increase in % of hospitalizations for hep A covered by Medicare (12.4% to 22.7%) -- reflecting the more advanced age of those hospitalized      

JAMA presented a randomized controlled drug-company sponsored trial assessing the utility of varenicline for patients who are not quite ready to quit smoking (see  smoking varenicline slowly cutting down JAMA 2015  in dropbox, or JAMA.  2015;313(7):687-694). details: --760 patients from 61 centers in 10 countries were randomized to varenicline titrated to 1mg bid (vs 750 placed on placebo). all patients felt they were not ready to quit within the next month but were willing to reduce smoking and make a quit attempt within the next 3 months. --mean age 45. 56% men, 62% white, 5% black, 23% asian. average 20 cigarettes/d. 20% never attempted to quit before, 25% tried once, 16% twice and 40% at least 3 times --patients had a reduction target of 50% or more by 4 weeks, 75% or more by 8 weeks, then a quit attempt by 12 weeks --primary endpoint: carbon monoxide-confirmed self-reported abstinence during weeks 15-24. secondary outcomes were carbon-monoxide-confirmed self-reported ab