geoffrey modest medical blogs

A recent study tested the hypothesis that it might be useful to initiate buprenorphine/naloxone treatment in the emergency room for patients with opioid dependence (see  opioid dependence subox in ER jama 2015  in dropbox, or JAMA .  2015;313(16):1636-1644). details: --329 opioid-dependent patients coming into a large urban teaching hospital emergency department in New Haven CT (mean age 31, 76% men, 75% white/7% black/16% hispanic, 41% high school grads/41% with at least some college, 52% full time employed, 32% with private or commercial insurance, 55% going to private physician or clinic for care. 34% came to ED seeking opioid treatment. 25% used only prescription opioids, 53% reported IV drug use. 88% smoked cigarettes, 55% used cocaine, 53% cannabis and 47% sedatives. alcohol use to the level of intoxication in 1/3 of the sample. >50% with prior psych treatment. --randomized to referral group (screening and refer for treatment); brief intervention (screening, brief inter

a new article just came out of the Program in Placebo Studies in Boston that link the "placebo effect" to specific genes in the newly-defined " placebome " (​see  placebo genetics  trendsmolecmed  2015  in the  dropbox ​, or  http:// dx.doi.org /10.1016/ j.molmed.2015.02.009  ), also noted in a more popular forum:  http://hms.harvard.edu/news/placebome?utm_source=Silverpop&utm_medium=email&utm_content=s3&utm_campaign=04.20.15.HMS ​ background, promoting the concept that placebo effects are legitimate biological responses to environmental cues: --studies on placebos have dated back decades. old studies have found red placebos and those in capsule form to be more effective. another found that blue placebos are more effective for sleep, across cultures (though, per NPR, not so only for males but not females in Italy, where blue perhaps evokes images of their national soccer league and may increase arousal). --other old studies have found that in so

The preliminary results of the TECOS trial (Trial Evaluating Cardiovascular Outcomes with Sitagliptin) was just released by the drug company (Merck), though formal release is expected in June at the Am Diabetes Assn meeting (and, i do not have an advanced copy to critique in detail).  This issue takes on added importance since there were 2 other large trials released recently on other DPP-4 inhibitors (dipeptidyl peptidase-4 inhibitors) finding possible increases in hospitalizations for heart failure. the SAVOR-TIMI 53 trial found a significant 27% increased hospitalization rate for heart failure in those randomized to saxagliptin (though no effect on cardiovascular outcomes overall, defined as cardiovascular death, nonfatal MI, or nonfatal ischemic stroke). the EXAMINE trial found a trend to higher heart failure hospitalization in those of alogliptin. based on these findings the FDA did recommend that these trials' results be added to the drugs' labels.  the TECOS trial, as r

yet another study on the relationship (or lack ​thereof) between MMR vaccination and autism. i bring this up since this is a large study but includes kids at higher risk of autism  ( see  vaccine MMR and autism JAMA 2015 ​ in dr opbox, or  JAMA.   2015;313(15):1534-1540 ). this is a retrospective cohort study from a large health insurer (Optum) database, using claims data (the insurer is mostly in the south and midwest of the US, though does have people in all regions. 75% white, 9% Hispanic, 3.5% black and 3.5% Asian). details: --95,727 kids who had older siblings. Autism spectrum disorder (ASD) was defined as 2 claims with a diagnosis of autistic disorder or pervasive developmental disorder, including Asperger. all kids were continuously enrolled in the health plan from birth to age 5 during 2001-2012. -- 944 (1.04%) were diagnosed with ASD.  1929 had an older sibling with ASD, of which 134 (6.9%) were diagnosed with ASD, vs 860 (0.9%) of those without an older sib having ASD

The Am Acad of Neurology and Am Epilepsy Society just released an evidence-based guideline on the management of an unprovoked first seizure in adults (see  seizure rx first seizure neurol 2015  in dropbox, or  Neurology.  84; 16:  1705-1713). background: in the US, there are 150K adults annually who have a first unprovoked seizure, defined as a seizure (sz) of unknown etiology, or a seizure in relation to  a preexisting brain lesion or progressive CNS disorder.  they exclude seizures from acute symptomatic conditions (eg metabolic, traumatic, stroke). general comments and guidelines: --what is risk of recurrent seizures? studies were mostly done on tonic-clonic seizures, no randomization regarding using AEDs (anti-epileptic drug). but overall greatest risk of recurrent sz is in first year (approx 32%), which increases to 36% by 2 years, 40% by 3 years and then to 48% if >5years.   --does immediate treatment with AEDs change the short-term (2 year) prognosis of sz recurr

Several of the HIV drugs are associated with adverse lipid effects, as well as metabolic (eg, insulin resistance/diabetes) and cardiovascular complications. A recent study looked at the effects of dolutegravir (an integrase strand transfer inhibitor, INSTI) on cholesterol ( see  hiv dolutegravir lipids clin drug invest 2015  in dropbox, or Clin Drug Investig (2015) 35:211–219). In this analysis they looked at 4 clinical trials of Rx-naive patients put on dolutegravir (DTG) and compared the lipid outcomes after 48 weeks to: efavirenz (EFV), raltegravir (RAL), or darunavir/ritonavir (DRV/r). In all of these studies dolutegravir was at least non-inferior clinically to these other agents. all of these meds were in combo with either tenofovir/FTC (TDF/FTC) or abacavir/3TC (ABC/3TC) as backbone therapy. details: --1118 patients: median age 37, 85% male, 75% white,  and randomized to dolutegravir 50mg qd in the 4 studies. approx 33% were on backbone therapy of abacavir/3TC. --for dolut

the US Preventive Services Task Task Force just published a draft recommendation for breast cancer screening in women after age 50 (see  http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/breast-cancer-screening1  ), as follows. for women 50-74 years old, screening mammography  every 2 years , grade B recommendation (moderate certainty that there is net benefit):     --meta-analysis suggests that screening 10,000 women age 50-59 over 10 years will result in 8 fewer breast cancer deaths; screening  10,000 women age 60-69 over 10 years will result in 21 fewer breast cancer deaths . these data are from really old studies. it is likely that current screening may detect more cancers but also that current treatment will decrease the deaths     ​--harms of screening: most important is overdiagnosis and overtreatment. hard to know for sure what the % is, depends on modeling methods used, but it is likely that the increased sensitivity of mammograph

a potentially very useful multicenter study was just published finding that lung ultrasound (LUS) was better than chest xray (CXR) in the diagnosis of acute decompensated heart failure (ADHF) in patients presenting to the emergency room (ER) with dyspnea ( see  chf lung ultrasound chest 2015  in dropbox, or CHEST 2015; 148(1): 202 - 210). This is an increasingly common issue, with evidently very different therapeutic approaches depending on the etiology.  details: --1005 patients from 7 Italian ERs presented with acute dyspnea, and the ER MD was asked  Apr 20, 2019  to categorize the dyspnea diagnosis as either from ADHF or noncardiogenic dyspnea, based on their initial clinical assessment (this was not prescribed but left up to the ER MD, to simulate a real-world situation) and after LUS. All patients also had CXR's. After patient discharge, independent reviewers  determined the cause of the dyspnea. --544 (51.4%) patients were in community hospitals, 461 (45.9%) academic me