geoffrey modest medical blogs

the US White House just released a report (see  https://www.cdc.gov/drugresistance/pdf/report-to-the-president-on-combating-antibiotic-resistance.pdf ) outlining a 5-point 5-year plan to  r educe and combat antimicrobial resistance, including plans to:         --improve surveillance efforts         --slow the emergence and spread of resistant bacteria         --develop rapid tests to identify and characterized resistant bacteria         --accelerate development of antibiotics and vaccines         --improve international collaboration specific targets include:         --c. difficile: reducing incidence of infection by 50% over 2011 estimates         --carbapenem-resistance Enterobacteriaceae infections acquired during hospitalization: reducing by 60%         --n. gonorrhoeae: maintaining ceftriaxone-resistance below 2%         --multi-drug resistant pseudomonas acquired during hospitalization: reducing by 35% over 2011 estimates         --methicillin-resistant s.

SAMHSA (substance abuse and mental health services administration) just released a 2014 report on where we are at in the US regarding substance abuse and mental health issues  (see  http://store.samhsa.gov/shin/content//SMA15-4895/National_BHBarometer_2014.pdf ​ ). a pretty brief summary: youth substance use/mental health  (note: there are different surveys used for these data):     --past month marijuana use, 2002-2013              --slight decrease in adolescents 12-17  to 7.1% (pe ak in 2011 at 7.9 %)             --9th-12th graders without much change, at 23%. 8th-10th graders at 12.5% (sl increase)     --past-year nonmedical pain reliever use, 2002-2013             --12th grade males: significant decrease, was up to 11.6% in 2002, decreased to mid-10 range til 2009, now down to 8.4%             --12th grade females: pretty flat at around 8% til 2011, then decreased to 5.6%             --age 12-17 males and females was in the 7.2% range, now decreased to 4.5-4.8%

The Advisory Committee on Immunization Practices of the CDC  just updated their HPV vaccination recommendations to include a 9-valent vaccine (see  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a3.htm?s_cid=mm6411a3_e ​ ). there are now 3 approved vaccines: Cervarix, a bivalent one against strains 16,18; Gardisil, a 4-valent one against 6,11,16,18; and now Gardisil-9, against 6,11,16,18,31,33,45,52,58. the 4-valent (4vHPV) and 9-valent (9vHPV) ones are licensed for use in men and women. data: --background: in the US 64% of invasive HPV-associated cancers are attributable to strains 16 or 18, and 10% are attributable to the new strains covered in  9v HPV . --phase III study comparing  9vHPV  with 4v HPV ​ in 14K females 16-26 yo found 96.7% efficacy to prevent >=CIN2 caused by the covered strains of 31,33,45,52,58 (there were very few caused by 6,11,16,18, but immunogencity against these strains was not inferior to that of 4 v HPV ) --seroconversion rates against all nine str

The US Preventive Services Taskforce ( USPSTF ) just published an update of their recommendations for  TSH  screening of  nonpregnant , asymptomatic adults (see  thyroid dysfunction screen  USPSTF  annals 2015  in  dropbox , or  doi:10.7326 / M15 -0483). For formal  USPSTF  recommendation, see http://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/thyroid-dysfunction-screening    Details: --definitions:      --hypothyroidism: subclinical = asymptomatic, serum  TSH  between 4.5-10 (varies a bit by lab), and normal  T3  and  T4 ; overt = can be asymptomatic, but high TSH  and low  T4  levels --hyperthyroidism: subclinical = asymptomatic,  TSH  < 0.4 and normal  T3 and  T4 . subdivided into "low but detectable", with  TSH  0.1-0.4, and "undetectable" with  TSH  <0.1. overt= can be asymptomatic, but has elevated  T3  or  T4 --detection:  TSH  is good for detection of thyroid abnormalities in the general population, but there is me

A study done in 4 centers (Univ of Chicago, San Francisco General Hosp, Harbor-UCLA , and Vanderbilt Univ Med Ctr) looked at the efficacy of clindamycin vs trimethoprim-sulfamethoxazole (TMP-SMX) for uncomplicated skin infections  (see  skin infections tmpsmx vs clinda nejm 2015  in dropbox, or N Engl J Med 2015;372:1093-103​) . the question was: which medication is preferred in the current era of community-acquired methicillin-resistant Staph aureus (MRSA), which seems to be extremely common around the country? details: --524 patients, including 155 children. 30.5% with abscess (>5cm, in adults), 53.4% with cellulitis, 15.6% with both; the patients were  52.3% male, 53.2% black, 40.3% white, 28.6% hispanic. mean age 27.1. 2 9.6% children. --patients were randomized to clindamycin (adults at 300mg tid) or  TMP-SMX  (on double- strength  tablet bid), all for 10 days. Pediatric doses adjusted by body weight -- of those with positive cultures (n=277), 217 had s. aureus [167 wi

two drug-company sponsored papers were published in new  engl  j of medicine comparing percutaneous coronary intervention (PCI) with coronary-artery bypass grafting ( CABG ), looking specifically at how the newer drug-eluting stents compare with surgery. 1. a large East Asian non-inferiority study with 27 centers randomly assigned patients with multi-vessel coronary artery disease (CAD) to PCI with  everolimus -eluting stent vs  CABG  (see  cad  cabg  vs stent  NEJM  2015  in  dropbox , or  DOI : 10.1056/ NEJMoa1415447 ). details: --880 patients were enrolled (only 1/2 of the anticipated). mean age 64, 70% male, BMI 25, 41% diabetic, 67% hypertensive, 20% current smoker, 53% hyperlipidemia. 47% with stable angina, 43% unstable angina, 9% acute MI in past 90 days; ejection fraction 59%; 77% with 3 vessel disease and 23% with 2 vessel disease (they excluded those with clinically significant left main disease) --primary endpoint: composite of death, MI, or target-vessel revascu

a rather disturbing but not unexpected article was just published in Lancet Psychiatry correlating suicide rates with unemployment (see  suicide and unemployment lancetpsych 2015  in dropbox, or Lancet Psychiatry 2015; 2: 239–45​ ). about 1 million people per year die by suicide around the world. prior data on the relationship between unemployment and suicide have been a bit mixed, though several studies have found a relationship and some with a time-lag.  this study looked at the 2008 world-wide economic crisis from a larger perspective than others: using databases from the WHO and the International Monetary Fund, the researchers looked at 63 countries (based largely on sample size and completeness of data) and assessed the long time period of 2000-2011, evaluating   suicide differences by  4 age groups and gender. as background, the 2008 economic crisis led to a 2% decline in world per capita GDP in 2009, and 31.8 million more people were unemployed in 2013 than 2007. results: -

​one factor often not considered in the breast cancer screening algorithm is the accuracy of the pathology report after biopsies. the widespread use of mammograms has led to lots of biopsies (1.6 million women in the US each year), with a reported approx 25% being positive for cancer. from 2011 to 2014 highly experienced pathologists from 8 states reviewed slides and the concordance of their readings was assessed  (see  breast biopsy discordance JAMA 2015  in dropbox, or JAMA. 2015;313(11):1122-1132​) . results: --65% of the invited pathologists consented to participate (n=115) and each given 60 slides to review from a total of 240 cases  (1 slide/case), including 23 cases of invasive cancer, 73 of ductal ca in situ, 72 with atypical hyperplasi a (atypia) , and 72 benign cases without atypia --49% of cases were in women 40-49yo, 50.8% had either heterogeneously dense or extremely dense breast tissue on mammogram, 57.5% were from core biopsies/42.5% excisional --pathologist imp

the American College of Cardiology meeting this week had several papers of potential clinical import. one was on the relative utility of using coronary CT angiography (CTA) vs stress testing (functional testing) in patients with likely symptomatic coronary artery disease (CAD) -- see  cad testing ETT vs CTA nejm 2015  in dropbox, or DOI: 10.1056/NEJMoa1415516​ -- the PROMISE trial, an NIH supported study. details: --10,003 symptomatic patients  who were felt to need non-urgent cardiac testing were randomly assigned CTA vs exercise testing (regular ETT in 10.2%, nuclear stress testing in 67.5%, or stress echo in 22.4%; 29.4% of these tests were pharmacologic), with median 25 months of follow-up --mean age 60.8, 52.7% women, 22.6% minority, 87.7% had chest pain (72.7%) or dyspnea on exertion (14.9%). mean pretest prob of CAD was 53.3%. also 21.4% had diabetes, 65.0% hypertension, 51.1% current or past tobacco use, 32.1% had family history (and patients had a mean of 2.4 of these 5