geoffrey modest medical blogs

one of the hardest tasks for us and our patients is maintaining weight loss in those who are overweight and obese. A recent NIH study looked at this issue, finding that people who had lost a lot of weight had long-term "metabolic adaptation" leading to a significant  lowering  of resting metabolic rate (RMR) and much less overall energy expenditure (see  obesity  wt  loss  dec  RMR obesity2016  in  dropbox , or doi:10.1002/oby.21538​ ). This study looked at 14 of the 16 "Biggest Loser" competitors from this televised weight-loss competition. details: --baseline: median age 35, 6 men/8 women, weight 149 kg, BMI 49.5 --At the end of the competition (30 weeks), through an aggressive program of diet and exercise, the mean weight loss was 58.3 kg, BMI deceased to 30, and the RMR decreased 610 kcal/day below baseline (this decrease in RMR was expected, as per a multitude of prior studies). --the following hormone levels improved dramatically after weight loss (at

STAT (see statnew.com) has frequent updates on Zika, noting the following: ·           --Puerto Rico reported the biggest weekly rise in Zika cases yet, with 1,336 new cases for the week ending June 30, including 533 pregnant women diagnosed with the virus ·           --Two patients who were infected with the Zika virus have developed severe thrombocytopenia ·           --Brazilian researchers have observed a sharp increase in cases of Guillain-Barré syndrome for this last point, there was a recent release of an article in Neurology (see doi:10.1212/WNL.0000000000003024 ​ ) from Brazilian neurologists who started a study group in Rio to further understand the Zika-related neurologic disorders ( Guillain-Barré  syndrome --GBS, meningoencephalitis, transverse myelitis), finding that in the period Dec 5, 2015 to <arch 18, 2016, there were:     --20 confirmed cases of GBS (there had previously been 15 case in 24 months prior to Zika: so average GBS cases increased from 0.

The International Antiviral Society--USA panel just released their 2016 recommendations for antiretroviral drugs for treatment and prevention of HIV infection in adults (see  hiv guidelines adult rx jama2016 ​ in dropbox, or Gunthard HF. JAMA 2016; 316(2): 191; and this group did include several HIV luminaries, such as Paul Sax from Brigham & Women's and Paul Volberding from UCSF). summary: --when to initiate therapy:     --everyone who has detectable virus, independent of CD4 count; and as soon as possible after acute HIV infection (to reduce the latent HIV reservoir, immune activation and perhaps protection against infection of central memory T cells)     --also in those with persistent undetectable virus without ART (antiretroviral therapy) if declining CD4 counts, which can occur in these "elite controllers", since they have higher levels of immune activation and increased cardiovascular risk. [I had such a patient who died in his 40s from lung cancer and

A rather disturbing MMWR just came out finding that gonorrhea is becoming increasingly resistant to pretty much all of our current antibiotics (see   http://www.cdc.gov/mmwr/volumes/65/ss/pdfs/ss6507.pdf  ). Details: --the Gonococcal Isolate Surveillance Project (GISP) has been around since 1986 and does sentinel surveillance of antimicrobial sensitivity for N. gonorrhoeae (GC). They check GC cultures and antibiotic susceptibility from the first 25 men with gonococcal urethritis attending each of the participating STD clinics at 27 sites in the US. --they are able to extract selected demographic and clinical data --mean age 28, 58% Black/22% white/13%Hispanic-Latino; 37% MSM or MSMF (men who have sex with men, or both men and women) --results:                 --5093 isolates were collected in 2014 (all of the resistance patterns were more common in MSM)                                 --25.3% resistant to tetracyclines                                 --19.2% resistant

A study looked at the sensitivity/specificity of the current USPSTF guidelines for diabetes screening in a community setting, finding over half the cases are missed (see  dm a1c USPSTF misses half PLoS2016 , or  http://journals.plos.org/plosmedicine/article/asset?id=10.1371%2Fjournal.pmed.1002074.PDF ​ ). The USPSTF in 2015 recommended diabetes screening for those aged 40-70 and who are overweight/obese. details: --retrospective analysis of electronic health record data of 50,515 adult primary care patients seen between 2008-2010 in 6 health centers in the Midwest and Southwest, followed for up to 3 years (median 1.9). [this screening was prior to the 2015 USPSTF guidelines] ​--18,846 (37%) were >40 yo; 33,537 (66%) were overweight or obese; 39,061 (77%) were racial/ethnic minorities (35% Black, 334% Hispanic, 9% other) --they excluded patients with dysglycemia (glucose intolerance or diabetes) at baseline --they then compared the actual findings of dysglycemia (by the us

The American Heart Association has published a long article on  medications  which could cause or exacerbate heart failure (HF). For the complete text, see  http://circ.ahajournals.org/content/circulationaha/early/2016/07/11/CIR.0000000000000426.full.pdf,  or  chf meds exacerbate AHA2016  in dropbox) --HF is the leading hospital discharge diagnosis in patients >65yo. This group has a very high medication burden (given their age and the likelihood that they have multiple risk factors and medical comorbidities), and on average are on 6.8 medications/d with 10.1 doses/d, not including OTCs (over-the-counter meds) and CAMs (complementary and alternative meds). In one study, 88% of HF patients used OTCs and 35% herbal supplements/63% vitamins. These multiple meds expose patients to more adverse drug effects, exacerbated by the increased likelihood for drug-drug interactions --these are the commonly used primary care drugs listed in the article:     ​--NSAIDs - pretty well-docume

The USPSTF strongly recommends low-dose chest CT (LDCT) annual screening for ever-smokers with >30 pack-year smoking history aged 55-80 or until they are 15 years after stopping smoking, based on the 3-year National Lung Screening Trial ( NLST ). JAMA just published an article evaluating the use of risk models/individual risk-based strategies to help focus the LDCT intervention (see  lung cancer CT screen risk model jama2016  in dropbox, or  doi:10.1001/jama.2016.6255 ). By looking at individual lung cancer risk beyond the criteria of NLST, they actually found relatively  higher risk  in some patients with a low risk by NLST (and therefore no screening done in NLST or offered by USPSTF) but a  low risk  for many included in the USPSTF guidelines. of note, there is no currently accepted validated risk tool for lung cancer for population screening. details: --they looked at 3 databases: the CXR-only wing of the NLST (2002-2009), the ever-smokers control group of the Prostate, Lun