geoffrey modest medical blogs

The Massachusetts Medical Society just sent out guidelines on opioid therapy prescribing (see  http://www.massmed.org/Patient-Care/Health-Topics/Massachusetts-Medical-Society-Opioid-Therapy-and-Physician-Communication-Guidelines/#.VV8R6blATcs  ).  A brief summary: --most of the guidelines are pretty self-evident:      ​--for initiation of opiates: screen the female patients for pregnancy (and counsel re: risks)     --do some form of screening for risk of opiate abuse [i would add that the website mytopcare.org has lots of useful tools for opiate prescribing, including an opioid risk tool to assess for risk of opioid addiction. i would also add that this type of risk tool is a not-completely-accurate instrument].     --inform patients of cognitive issues with taking opiates, and potential risks of operating heavy machinery, driving     --consider consultation if patient has complex pain issues with serious co-morbidities and mental illness, or history of substance abuse dis

A pretty common primary care conundrum is what to do with patients who are on warfarin but have impending surgery: stop the warfarin and hope they don't get a pulmonary embolus, or do bridge therapy (there are several different ways to do the bridging: for those at high risk of venous thromboembolism --VTE, full-dose bridging is often done: stopping the warfarin 5 days prior to surgery, starting low molecular-weight heparin soon thereafter, stopping that for the surgery, and then restarting the heparin soon after the surgery (can be 1 day in those at low risk of post-op bleeding, longer if at higher risk); can do prophylactic low-dose heparin post-op; or can do intermediate (about 1/2 full-dose) for those with higher risk (eg VTE within the past month). Warfarin is resumed 12-24 hours post-op and usually takes 4-6 days to achieve target anticoagulation. A recent study in JAMA Internal Medicine looked at the outcome of 1178 patients in a retrospective cohort study in a large HMO (K

There was a systematic review of fecal microbiota transplantation (FMT) for Clostridium difficile infections in the Annals of Internal Medicine recently  (see  cdiff  fecal  tx  review annals 2015  in  dropbox , or DOI: 10.1093/cid/ciu135). Despite the reasonably large number of articles written on this treatment, typically for very difficult recurrent or refractory cases, there have only been 2 small RCTs, and only 1 which compared fecal transplant with medication. There were also 28 case series reported (several of the studies have been blogged in the past: see  http://gmodestmedblogs.blogspot.com/search?q=c+difficile   for some prior studies and comments on FMT for C diff, and  http://gmodestmedblogs.blogspot.com/search?q=microbiome    for some articles on the microbiome). the findings of the systematic review: --C diff infections (CDI) are common and have a high rate of recurrence (up to 30% after an initial infection, and increasing thereafter). data on the utility of FMT:

in response to blog on H pylori and  (see  http://gmodestmedblogs.blogspot.com/2015/05/h-pylori-and-nsaids-increased-gi.html ),  see comment, from katie harris: Totally anecdotal -  but I have had several patients with chronic urticaria,  get treated for  h.pylori and the urticaria resolved!  given the other reasons to treat h pylori, may be worth checking serology and treating patients with chronic urticaria.  the literature i have found is mixed, but one pretty positive study: see  https://www.ncbi.nlm.nih.gov/pubmed/19416374  

JAMA just had an article on the utility of oral steroids in patients with acute sciatica (see lbp disc steroids jama 2015  in dropbox, or  JAMA.  2015;313(19):1915-1923). The goal of this study was to see if short-term oral prednisone was effective in improving disability and pain, as well as decrease the need for invasive procedures. Details: --randomized controlled trial in Kaiser California comprising 269 adults (mean age 46, 55% male, baseline Oswestry Disability Index ODI  score of 51, with 100 being the worst, and pain score of 6.7, with 10 = worst). All had radicular pain < 3 months (mean 30 days), and  a herniated lumbar disc documented on MRI. Prednisone was given as 60 mg x 5 d, then 40 mg x 5 d, than 20 mg x 5 d. --primary outcome was ODI score change at 3 weeks; secondary outcome was ODI change at 1 year, change in lower extremity pain, spine surgery and Short Form 36 Health Survey (SF-36) Physical and Mental Component summaries. [note: there is no clear consensus

A recent Spanish study looked at the risk of peptic ulcer bleeding in patients with H Pylori (HP) infection and in patients also using NSAIDs/low-dose aspirin ( see  hpylori gi bleed asa nsaid amjgastro 2015  in dropbox, or Am J Gastroenterol 2015; 110:684–689). This case-control study looked at 666 patients with endoscopically-confirmed major peptic ulcer bleeding and 666 controls (matched by age, sex, month of admission), assessing medication use in the prior 7 days. HP was assessed by serology. results: --mean age 60; 29% female; with cases having significantly more smokers, ulcer history, dyspepsia, use of aspirin or NSAIDs, being on anticoagulants, not being on PPIs, and having HP infections (the latter being in 74.3% of cases and 54.8% of controls,   [ R R: 2.6  (CI:  2.0-3.3) ]) --results:     ​--aspirin use (<300 mg/d) was associated with 15.8% of cases vs 12% of controls [RR: 1.9 (CI: 1.3-2.7)].      --NSAID use was associated with 34.5% vs 13.4% of controls  [ R

 a prospective observational study looked at a large number of low-risk patients admitted for chest pain and their outcomes ( See  chest pain low risk not admit jamaintmed 2015  in  dropbox , or  doi:10.1001 / jamainternmed.2015.1674 ). data was collected from July 2008 until July 2013 from the emergency depts (EDs) of  3 academic  mid-Western US hospitals . details: --45,416 patients were seen for chest pain, and 22,457 (49.5%) were admitted, of whom 11,230 met inclusion criteria of: primary presenting symptom of chest pain, chest tightness, chest burning or chest pressure; and two negative serial troponins, 60-420 minutes apart --primary outcome was short-term (ie, during the hospitalzation) development of life-threatening arrhythmias, inpatient ST-segment elevation MI (STEMI), cardiac or respiratory arrest, or death during hospitalization (ie, CRACE, or clinically relevant adverse cardiac events). --mean age 58, 44.8% arrived by ambulance, 55% women. hypertension in 46%, di

The FDA just came out with a warning on the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors, including canagliflozin dapagliflozin, and empagliflozin (and the combo drugs including them) because of 20 cases of ketoacidosis. these drugs lead to increased urinary excretion of glucose, thereby lowering hemoglobin A1C. see  http://www.fda.gov/Drugs/DrugSafety/ucm446845.htm ​  for the press release. findings of FDA: --from March 2013 to June 2014, there were 20 cases of ketoacidosis reported requiring emergency room visits, an unusual finding in type 2 diabetes. and there have been additional reports since June 2014. --1/2 the cases did not have any typical DKA triggering factors, such as acute illness (urinary tract infection, urosepsis, gastroenteritis, influenza, trauma), reduced caloric or fluid intake, reduced insulin dose; also no factors associated with high anion-gap acidosis (hypovolemia, acute renal failure, hypoxemia, reduced oral intake, history of alcohol use)

A​n Italian prospective study was just published looking at the merits of ultrasound in diagnosing pneumonia  (see  pneumonia dx ultrasound am j em med 2015  in dropbox, or  Am J Emerg Med   2015   May ;  33 : 620 . ). prior studies have found that chest xray (CXR) is not so sensitive, 43.5% in one study when compared to chest CT (which is considered the gold standard).  details: --275 patients with respiratory complaints (60% dyspnea, 25% cough, 10% purulent sputum, 15% pleuritic chest pain) and underwent chest CT. mean age 71, 53.3% women.  --Chest CT was positive for pneumonia (PNA) in 87 patients, with "almost perfect" concordance between the readings of 2 radiologists. --lung ultrasound (LUS), done within 3 hours of the CT, and was positive in 81 patients. 72 of them (88.9%) also had a positive chest CT     --the 9 false positives were: 3 lung cancer nodules, 3 cases of impaired ventilation not due to PNA, 3 cases of fibrotic bands     --the 15 false negativ

a recent article, which got some general press, looked at the utility of exercise and/or vitamin D in fall prevention in older women (see  vit d not prevent falls jama int med 2015  in dropbox, or JAMA Intern Med. 2015;175(5):703-711). The backdrop here is that falls are common in the elderly, and 20% lead to injury requiring medical attention. a systematic review and meta-analysis documented the benefit of vitamin D (see  vit d and falls metanalysis 2011  in dropbox, or J Clin Endocrinol Metab, October 2011, 96(10):2997–3006), finding that in 26 studies with 46K people (majority elderly women), vitamin D was associated with 14% decreased risk of falls (47% in those vitamin D deficient, 10% in those not deficient, and both statistically significant), and this was especially true in patients who had calcium co-administered with the vitamin D. The US Preventive Services Task Force (USPSTF) in 2012 " recommends exercise or physical therapy and vitamin D supplementation to prevent f