geoffrey modest medical blogs

As mentioned in prior blogs (see below), i think the data are quite good for quantitative coronary artery calcium (CAC) as a marker for future clinical coronary artery disease (CAD). but the big issue to me is the excess radiation exposure. however, loads of patients are getting chest CTs for a variety of reasons, and a recent article found that CAC scoring on routine chest CTs is quite a good predictor of mortality (see  CAD calcium score from chest CT jacccardiovasc2016 in dropbox, or J Am Coll Cardiol Img 2016;9:152). details: --4,544 community-living people (mean age 68, 63% male) had "whole-body" CT scans, which included both EKG-gated CTs with 3mm cuts for their CAC scores and 6 mm chest CTs. All were done between 2000 and 2003, with mortality followup through 2009. --157 people died, and these were matched with 494 controls by sex and age. --cases and controls were well-matched for BMI, total cholesterol, HDL, and use of lipid-lowering agents. not so well

As mentioned in prior blogs (see below), i think the data are quite good for quantitative coronary artery calcium (CAC) as a marker for future clinical coronary artery disease (CAD). but the big issue to me is the excess radiation exposure. however, loads of patients are getting chest CTs for a variety of reasons, and a recent article found that CAC scoring on routine chest CTs is quite a good predictor of mortality (see  CAD calcium score from chest CT jacccardiovasc2016  in dropbox, or J Am Coll Cardiol Img 2016;9:152). details: --4,544 community-living people (mean age 68, 63% male) had "whole-body" CT scans, which included both EKG-gated CTs with 3mm cuts for their CAC scores and 6 mm chest CTs. All were done between 2000 and 2003, with mortality followup through 2009. --157 people died, and these were matched with 494 controls by sex and age. --cases and controls were well-matched for BMI, total cholesterol, HDL, and use of lipid-lowering agents. not so well-con

the lancet just reported a study looking at a rapid, low-cost urine test to guide TB treatment in HIV-positive individuals in areas with high TB prevalence  (see  TB urine test in HIV  lancet2016  in dropbox , or Lancet 2016; 387: 1187). --background:     --TB is the leading cause of death in people  with  HIV, accounting for 360K deaths in 2013; post-mortem analysis in resource-limited countries find that TB is the cause of death in about 40% of HIV-infected people, in 85% of cases it is disseminated, and half are undiagnosed at the time of death     --those with HIV have a higher case-fatality rate when co-infected with TB: increased disseminated extra-pulmonary TB, more severe TB as immunocompromise increases.     --it is harder to diagnose TB in those with advanced immunosuppression, since they often have low bacillary loads in their bodily fluids, reducing the sensitivity of smears and cultures     ​--there is a urine test detecting the lipoarabinomannan Ag (LAM), a g

​i just sent out the review from AHRQ on  low   back   pain  (LBP) management, noting that  psychological therapies (especially restoration or cognitive-behavioral therapies) have small-to-moderate effect for improving  pain  or function ​ (for full review of pharmacologic and nonpharmacologic therapies, see  http://blogs.bmj.com/ebm/ 2016/03/17/primary-care- corner-with-geoffrey-modest- md- low - back - pain -treatment- per-ahrq-review/  . a new study was just published in JAMA on the efficacy of mindfulness-based  stress  reduction (MBSR) in reducing  pain and improving function in those with chronic  low   back   pain  (see JAMA. 2016;315(12):1240​). this  study was sponsored by the National Center for Complementary and Alternative Medicine of  the NIH.  details: --342 adults aged 20-70 with chronic  low   back   pain  of at least 3 months, recruited from 2012-2014 and randomly assigned to MBSR or cognitive behavioral therapy (CBT) vs usual care --mean age 49.3, 65.7% women,

i just sent out the review from AHRQ on low back pain (LBP) management, noting that  psychological therapies (especially restoration or cognitive-behavioral therapies) have small-to-moderate effect for improving pain or function ​ (for full review of pharmacologic and nonpharmacologic therapies, see  http://gmodestmedblogs.blogspot.com/2016/03/low-back-pain-treatment-per-ahrq-review.html  . a new study was just published in JAMA on the efficacy of mindfulness-based stress reduction (MBSR) in reducing pain and improving function in those with chronic low back pain (see  lbp stress reduction helps jama2106  in dropbox, or JAMA. 2016;315(12):1240​). this  study was sponsored by the National Center for Complementary and Alternative Medicine of  the NIH.  details: --342 adults aged 20-70 with chronic low back pain of at least 3 months, recruited from 2012-2014 and randomly assigned to MBSR or cognitive behavioral therapy (CBT) vs usual care --mean age 49.3, 65.7% women, 82.5% white/6

a retrospective cohort analysis of participants in the National Lung Screening Trial (NSLT), the trial that propelled forward low-dose lung CT  (LDCT) ​ screening in smokers, found that those with a negative initial LDCT actually had a much lower subsequent incidence of lung cancer and that annual screening may not be necessary (see  lung cancer CT screening not nec lancetoncol2016  in dropbox, or doi.org/10.1016/ S1470-2045(15)00621-X​). see blogs at the end for details and my analysis of the NSLT study, and the  perhaps  overenthusiastic guidelines than ensued. details: --26,231 people were screened, according to the criteria: aged 55-74, with at least a 30 pack-year history of cigarette smoking, and, if a former smoker, had quit within the past 15 years. they had 3 annual LDCT screens and were followed for 5 years after the last screen. --19,066 (73%) had a negative initial screen --results:     --those with a negative initial screen had a lower incidence of:           

the lancet just published a network meta-analysis of NSAIDs, acetaminophen, or placebo for hip or knee osteoarthritis (OA) pain (see  osteoarthritis lack of acetaminop benefit lancet2016  in dropbox, ordoi.org/10.1016/ S0140-6736(16)30002-2​). a network meta-analysis is a mathematical device which allows one to infer the comparative effectiveness of different interventions from different randomized clinical trials, even though there may not have been actual trials with direct comparisons. details: --74 RCTs were included in the analysis with a total of 58,556 patients with predominantly knee or hip OA. all trials had at least 100 patients per group and had prespecified primary and secondary outcomes of pain and physical function. --they developed a network comparison chart with 23 nodes, each with a treatment (several nodes had the same drug but in different doses), and the relationships between them. --results:     --when looking at what was considered a clinically signific

i was going through piles of old medical articles, intent on throwing them out in this electronic age, but then found one from 2005 looking at the use of cimetidine for warts (see  plantar warts cimetidine ampodmedj2005  in dropbox, or J Am Podiatr Med Assoc 95(3):229). i have had several very impressive cases where using cimetidine, an H2-blocker but also used in the past as an immunoenhancer for some chemotherapy regimes, really worked. the first case was a 5yo male i saw about 25 years ago with very extensive longstanding perianal warts (condyloma acuminata). the dermatologist was planning rather extensive surgery, but commented to me that there were often responses to cimetidine. the patient took the med and the warts completely vanished within 1-2 weeks. the second case was me, complaining of a rather painful plantar wart. i saw our podiatrist, who tried liquid nitrogen therapy (which exceeded my pain threshold, though i had thought that was very high). so, i tried   imiquimod  

i have recently blogged on a Taiwanese study finding that in patients with gout, treating them with urate lowering therapy (ULT) was associated with a dramatically decreased incidence of cardiovascular disease (see  http://gmodestmedblogs.blogspot.com/2019/04/uric-acid-lowering-cardiovasc-benefit.html   . the blog also has a section looking at an interesting evolutionary perspective on why great apes and humans developed a non-functioning uricase enzyme. a recent Danish epidemiologic study using allopurinol found the same decreased cardiovascular disease as the Taiwan study (see  gout allopurinol dec cardiovasc AmJMed2016  in dropbox, or  doi.org/10.1016/j.amjmed.2015.11.003 ​). details: --they looked at the medical data from all patients in Funen County in Denmark, scouring the blood samples done, all in- and out-patient hospital contacts, all reimbursed prescriptions and causes of death --of 65,971 people, 7127 had hyperuricemia (uric acid >= 6mg/dl), and propensity-score m